The European Union has 28 Member States (27 after the expected departure of the UK) and around 512 million people (about 446 million without the UK), making it one of the world’s largest political units compared to the US (327 million), China (1 386 million), India (1 399 million) and Japan (126 million).
It is also extremely diverse – economically, culturally, politically and in health terms. For understanding the background of health policy in particular, it is worth remembering both the different economic and health outcomes and the extent of convergence. In particular, it is worth noting the extent to which convergence between different Member States is not clearly continuing, whether in GDP (which was in France 1.160 trillion (current) US dollars in 1995, 2.196 trillion in 2005 and 2.438 trillion in 2015; in Spain 612.94 billion (current) US dollars in 1995, 1.157 trillion in 2005 and 1.199 trillion in 2015; and in Greece 136.878 billion (current) US dollars in 1995, 247.783 billion in 2005 and 196.591 billion in 2015)26 or life expectancy at birth (which was in France 77.751 years in 1995, 80.163 in 2005 and 82.322 in 2015; in Spain 77.981 years in 1995, 80.171 in 2005 and 82.832 in 2015; and in Greece 77.585 years in 1995, 79.239 in 2005 and 81.037 in 2015).27 Perhaps unsurprisingly, the percentage of GDP spent on health varies substantially (in France, 10.18% of GDP in 2005 and 11.501% in 2015; in Spain 7.676% in 2005 and 9.12% in 2015; and in Greece 8.997% in 2005 and 8.194% in 2015).28 More surprising perhaps is the variation in healthy life years relative to life expectancy, which among other things shows and predicts the extent to which older people are faring well (average healthy life years at birth were, for Swedish men, 67 years in 2010 and 72 years in 2016; for Danish men, 60 years in 2010 and 62 years in 2016; and for Slovakian men, 52 years in 2010 and 57 in 2016).29
In other words, convergence within the EU is neither inevitable nor necessarily proceeding under the current policy regime. Fig. 1.1 shows trends in convergence in GDP per capita since 1995, showing that overall economic convergence is
26 World Bank Data. “GDP (current US$)”. Available at: https://data.worldbank.org/indicator/NY.GDP.
MKTP.CD?locations=FR-ES-GR.
27 World Bank Data. “Life expectancy at birth, total (years)”. Available at: https://data.worldbank.org/
indicator/SP.DYN.LE00.IN?locations=FR-ES-GR.
28 World Bank Data. “Current health expenditure (% of GDP)”. Available at: https://data.worldbank.org/
indicator/SH.XPD.CHEX.GD.ZS?locations=FR-ES-GR.
29 Eurostat. “Healthy life years at birth, male, 2010 and 2016”. Available at: https://ec.europa.eu/eurostat/
statistics-explained/index.php?title=File:Healthy_life_years_at_birth,_males,_2010_and_2016_(years)_
YB17.png.
Box 1.5 Well-being
The treaties state the overall aim of the EU as being “to promote peace, its values and the well-being of its peoples” (emphasis added).a Although not directly a reference to health, this of course echoes both the World Health Organization’s definition of health (“Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”)b and the objectives for improving well-being set by the WHO’s European “Health 2020” strategy.c The treaty aim does not have any specific powers attached to it – rather, all the powers in the treaties are intended to help to achieve this overall aim. There has been some specific work related to this, however, centered on the idea of developing broader measures of progress in European countries than the traditional summary of GDP,d within which health is one of the main dimensions. This has been followed by a range of reports and publications by the EU, by Member States and by other international bodies.e
It has received a push in 2019. The Finnish Presidency of the Council released draft conclusions (for the September EPSCO meetingf) on the economy of well-being as a “policy orientation and governance approach” that “brings into focus the raison d’être of the EU as enshrined in the treaties and in the Charter of Fundamental Rights of the European Union”. An economy of well-being, it continues, entails cross-sectoral collaborations (noting Health in All Policies) and includes access to healthcare, “promotion of health and preventative measures” and “occupational health and safety”.
However, although there is by now an extensive range of reports and evidence highlighting the relevance of these broader concepts of development and well-being and the importance of health as one of the key issues, it is not clear that this evidence has yet brought about any substantive changes in policy-making. With the agreement of the Sustainable Development Goals (SDGs) in 2015, it may be that in practice the SDGs and their monitoring will prove to be the primary focus for efforts to take a broader perspective on development, rather than the concept of well-being.
a Treaty on the European Union, Article 3.
b Preamble to the Constitution of the WHO as adopted by the International Health Conference, New York, 19–22 June 1946, signed on 22 July 1946 by the representatives of 61 States (Official Records of the World Health Organization, no. 2, p. 100) and entered into force on 7 April 1948.
c WHO Regional Office for Europe (2013). The European health report 2012: charting the way to well-being and Health 2020: a European policy framework and strategy for the 21st century. Copenhagen: WHO Regional Office for Europe.
d European Commission (2009). Communication: GDP and beyond – measuring progress in a changing world (COM(2009)433). Brussels: European Commission.
e See http://ec.europa.eu/environment/beyond_gdp/index_en.html for more information.
f Council of the European Union (21 June 2019). The Economy of Well-Being. Executive Summary of the OECD Background Paper on “Creating opportunities for people’s well-being and economic growth”. Brussels. Available at: https://data.consilium.europa.eu/doc/document/ST-10414-2019-INIT/en/pdf.
not the main story of the twenty-first century EU. Trends in health show a similar pattern.
1.7 Conclusion
In the EU, having a legal basis provides the crucial authorization for policy entrepreneurship,30 but the public health legal basis is so weak as to impede even discussion of possible fruitful EU health policy.
To sharpen the point, the EU treaties prevent much activity grounded in the public health article, but that manifestly does not mean that the EU lacks health policy. Instead, it means that the EU’s health policies are made under other guises, as part of efforts to promote and regulate the internal market, to ensure the protection of workers, consumers and the environment, to invest in poorer regions or to monitor the fiscal decisions of its Member States. There are powerful tools there, but in each case they legally, politically and practically
30 Page EC (2012). “The European Commission Bureaucracy: Handling Sovereignty Through the Back and Front Doors”, in Hayward J & Wurzel R (eds.). European Disunion: Between Sovereignty and Solidarity.
Basingstoke: Palgrave Macmillan.
Fig. 1.1 GDP per capita, PPP (current international $)
1995 2000 2005 2010 2015
40 000
30 000
20 000
10 000
GDP per capita
EU 15 Eastern member states
Source: Makszin K (forthcoming). “The East-West Divide: Obstacles to European Integration” in Greer SL and Laible J (eds.), The European Union after Brexit. Manchester: Manchester University Press.
belong to another sector. There can be and is an EU policy on acceptable rules for developing baskets of covered healthcare services, but it cannot be made with health as its declared primary goal, just as there are EU recommendations, some very specific and backed by the threat of fines, to Member States about how to operate their health systems, but they cannot primarily be made with health, as against fiscal sustainability, as their goal.
If Article 9’s commitment that the EU shall always take into account “protection of human health” is to carry any weight, the solution cannot be limited to the weak public health treaty article; it will be in understanding and finding ways to gain leverage over multiple powerful and promising elements of EU policy, from the European Semester to medical devices regulation.
The last five years have shown what can be done within the limits of Article 168 and an overall EU political agenda that was focused elsewhere. Health policies we discuss range from the State of Health in the EU reports to tobacco control and European Reference Networks, and the Commission, particularly DG SANTE, has taken action in crucial areas such as healthy lifestyles, vaccination and antimicrobial resistance. Combined with action across the EU’s many other policies, where health has gained prominence over the term of the Juncker Commission, the result has shaped health outcomes and shows how powerful, and inescapable, EU health policy can be. Comparing the very minimal goals of the 2014 Mandate letter to Commissioner Andriukitis with the results we describe in this book makes the point: health can be put on the EU agenda and advanced as a goal even against political headwinds.