Global health voice

The same 2010 Communication and Council Conclusions¹⁴⁸ that underpin the EU’s development aid also encourage the EU to develop its own policy coherence among different elements of the EU that affect global health, including trade policy, health policy, civil protection policy and development aid. It also calls on

145 https://ec.europa.eu/europeaid/sectors/human-development/health_en.

146 The New European Consensus on Development, ‘Our World, Our Dignity, Our Future’, joint statement by the Council and the Representatives of the Governments of the Member States meeting within the Council, the European Parliament and the European Commission. Available at: https://ec.europa.eu/

europeaid/sites/devco/files/european-consensus-on-development-final-20170626_en.pdf.

147 COM(2010)128 final. Communication from the Commission to the Council, the European Parliament, the European Economic and Social Committee and the Committee of the Regions. The EU Role in Global Health and Council conclusions on the EU role in Global Health. 3011th Foreign Affairs Council meeting, Brussels, 10 May 2010.

148 COM(2010)128 final. Communication from the Commission to the Council, the European Parliament, the European Economic and Social Committee and the Committee of the Regions. The EU Role in Global Health and Council conclusions on the EU role in Global Health. 3011th Foreign Affairs Council meeting, Brussels, 10 May 2010.

EU institutions and Member States to support the WHO, including a reduction in earmarked funding.¹⁴⁹

3.8 Research

Research has long been a major EU priority, with clear potential added-value from collaboration between scientists across Europe, with the largest part of the EU budget after the Common Agricultural Policy and the structural funds.

In general, research policy anywhere has some combination of three points of focus: it can be industrial policy (promoting industry and economic growth), science policy (promoting basic research, science infrastructure and knowledge), or substantive (focused on generating knowledge about a particular topic, such as climate change or health). EU research policy has never been primarily a science policy and has always had a strong industrial policy component. In the last decade in particular, it has been especially focused on industrial policy objectives.¹⁵⁰ Health has been a major priority within that, and the EU has funded thousands of health-related research projects.¹⁵¹ Despite the collective challenges facing the EU in terms of public health and health systems, described above, health-related research has tended to avoid these topics, primarily funding biomedical research of more general application instead.¹⁵²

This may change in the coming decades. The EU’s research programme Horizon 2020¹⁵³ has a broader focus than in the past on “health, demographic change and well-being”. Under Horizon 2020, health research fields include health, environment and lifestyle, mental health, foresight, health systems and services, research for maternal and child health, and global health, although in practice the biomedical approach has remained central. The increased EU focus on broader health system issues, for example the recommendations being made by the EU to Member States about health system reform through the processes of the European Semester, is likely to increase pressure to shift the focus of the EU’s funding to more relevant research in the years to come. The potential of the health systems of the Member States to learn from each other has been much

149 For a broader and more reflective analysis, see Hervey TK (2017). “The EU’s (emergent) global health law and policy”, in Hervey TK, Young C & Bishop L (eds.). Research Handbook on EU Law and Policy.

Cheltenham: Edward Elgar Publishing, pp. 453–78.

150 Greer SL, Kuhlmann E (2019). “Health and Education Policy: Labour Markets, Qualifications, and the Struggle over Standards”, in St John SK & Murphy M (eds.). Education and Public Policy in the European Union. London: Palgrave Macmillan, pp. 67–88.

151 Charlesworth K et al. (2011). Health research in the European Union: over-controlled but under-measured?

European Journal of Public Health, 21(4):404–6.

152 Walshe K et al. (2013). Health systems and policy research in Europe: Horizon 2020. Lancet, 382(9893):668–9.

153 European Parliament and Council (2013). Regulation (EU) No. 1291/2013 establishing Horizon 2020 – the framework programme for research and innovation (2014–2020) – and repealing Decision No. 1982/2006/EC. Official Journal, L 347:104.

discussed in principle, but has proved remarkably hard to do in practice. The TO-REACH project, for example, has aimed to address this by providing a basis for a joint European research programme on health services and systems. Its proposed Strategic Research Agenda outlines a European strategy to advance our knowledge and understanding of the adoption, implementation and potential scale-up of service and policy innovations and their translation to other settings within and across countries. Given the shared challenges facing European health systems, realizing the potential of learning and working together should become an increasingly central part of European health research.

Of course, the EU’s funding for research is only a small part of total public funding for research in the EU. The bulk of funding comes from national governments, directly or through higher education, and through industry (mostly for more applied technology). National, regional and private strategies are not coordinated, and many EU countries have lacked overall strategies for health research.¹⁵⁴ Consequently part of the EU’s role has become not only to fund research but also to help to coordinate European funding of research more generally to maximize effectiveness and avoid duplication. This has been the case through examples of “joint programming initiatives”, including on the specific health topics of Alzheimer’s disease and other neurodegenerative diseases, healthy diet and physical activity, antimicrobial resistance and the implications of demographic change.¹⁵⁵ There is, as yet, no more general strategy for coordination of research across Europe in relation to the challenges faced by health systems;

again, this may emerge onto the agenda in the coming years with the increasing policy focus on these questions.¹⁵⁶

3.9 Conclusion

The pioneering work of the Commission on Social Determinants of Health led by Professor Sir Michael Marmot underlined the importance of social factors for health. This, however, is the area where the “constitutional asymmetry” of the EU in regard to health is clearest. While the EU has significant action on some of the social determinants that the Commission identified (in particular working conditions, as discussed in section 3.2.5, and more general protection of employment conditions), questions of income, tax, social protection and the extent of solidarity within societies are some of the core areas reserved by Member States for national action rather than being EU responsibilities. The

154 Grimaud O, McCarthy M, Conceicao C (2013). Strategies for public health research in European Union countries. European Journal of Public Health, 23(suppl 2):35–8.

155 European Commission. Joint programming initiatives. Brussels: European Commission. Available at:

http://ec.europa.eu/research/era/joint-programming-initiatives_en.html, accessed 4 July 2014.

156 Walshe K et al. (2013). Health systems and policy research in Europe: Horizon 2020. Lancet, 382(9893):668–9.

powers of the EU to create an internal market have knock-on consequences (shifting employment in a particular profession from one country to another, for example). The social protection systems to ensure support such as unemployment protection and retraining, nevertheless, are a national responsibility. There is potential support from sources such as the European Social Fund, but this is, of course, relatively marginal in comparison with the cost of social protection systems overall.

This is not to say that the EU has been inactive. The EU has focused attention on issues such as access for all to education, social protection and healthcare;

creating jobs and equal opportunities; and promoting social inclusion; it has also specifically highlighted issues of health inequalities. A Charter of Fundamental Rights of the European Union has also been adopted, which includes a range of social provisions (see Appendix). The problem is that the principal tools to meet these objectives and rights, both legislative and overwhelmingly financial, are at national level, not European.

The first face of European Union health policy is shaped by the constitutional asymmetry of the EU and by its nature as a primarily regulatory state, as discussed in chapter 1. Constitutional asymmetry means that positive action such as health systems strengthening is limited by the difficulty of the EU legislative process, by subsidiarity as both a principle and an objective of many Member States, and by the EU budget, which is kept small. By contrast, action to remove Member State policies in the name of the internal market – the second face and focus of the next chapter – has stronger legal bases and benefits from the large and highly developed EU legal system. The EU’s reliance on regulation as its key policy tool, meanwhile, means that its greatest health effects are through law and regulation rather than through expenditure, and its effects via expenditure are often by shaping agendas, norms and networks rather than by actively financing activities. Thus the most effective and consequential EU health policies, viewed in the round, are regulatory, whether on food safety, environmental protection or the internal market.

Chapter 4