EU action for health
3.6 Health policy processes
Health, in part because the Article 168 treaty base is so limited, has been the scene of quite a lot of experimentation in newer forms of governance that seek to coordinate and change policy through means other than hard law. This section presents some of the key initiatives intended to improve health policies and systems, which means that it does not cover measures built primarily out of internal market law. Those are discussed in chapter 4. In particular, Directive 2011/24/EU on Patients’ Rights in Cross-Border Healthcare was a response to Member State and European courts’ application of internal market law to healthcare, discussed in section 4.3.1. It emerged from debates about the proper application of internal market law even if by the end the Directive recognized the specificity of health thanks to interventions such as the 2006 Council Conclusions (see section 1.5). It became the basis for initiatives in areas such as e-Health, and healthcare quality that are discussed in sections 4.3.3–5. It is not to be confused with the European Convention on Human Rights, which is a separate Council of Europe instrument, but all of which is incorporated into the Charter of Fundamental Rights. The Fundamental Rights Agency advises on Charter issues.
Article 35, reproduced in the Appendix, specifically states a right to health care and health protection. Other articles incorporate health, e.g. Article 31 specifies a right to healthy working conditions.
3.6.1 State of health in the EU cycle
Developed in cooperation with the Organisation for Economic Co-operation and Development (OECD) and the European Observatory on Health Systems and Policies, State of Health in the EU is a two-year initiative undertaken by the European Commission that aims to provide health policy-makers and other relevant actors with comparative data into health systems in EU countries.134 Launched in 2016, the two-year State of Health in the EU cycle consists of four stages. The first began with the publication of Health at a Glance: Europe, a comparative overview of EU health systems. This 2018 joint report of the European Commission and the OECD found that the steady increase of life
134 European Commission. State of Health in the EU. Available at: https://ec.europa.eu/health/state/
summary_en.
expectancy in Europe has slowed down, and that health disparities according to sex and socioeconomic status persist both within and between EU Member States.135 The report also called for improving mental health, after 84 000 people died of the consequences of mental illness in 2015, and the total cost arising from lack of or undertreatment amounts to €600 billion per year. It also called for ensuring universal access to care, addressing risk factors such as smoking and drinking, and strengthening the resilience of health systems through, for instance, the pricing of pharmaceutical drugs through health technology assessment.
The second step in the cycle is the periodical publication of Country Health Profiles for all EU Member States. This joint publication of the European Commission, the OECD and the European Observatory on Health Systems and Policies gives a snapshot of each country’s population’s state of health and key risk factors, along with an analysis of each health system’s performance in terms of effectiveness, accessibility and resilience. The third step is the publication of a Companion Report, to be released alongside the Country Health Profiles, which links common policy priorities across EU Member States. Finally, when the project reaches the end of the two-year cycle, health authorities will be able to request voluntary exchanges with the experts behind the studies to discuss potential policy responses. This is not just an academic exercise. It substantially informs the European Semester (chapter 5, e.g. Box 5.2).
3.6.2 Health programme
A core tool for the EU’s specific action on health has been financing collaborative projects on health. This started as a series of topic-specific programmes (e.g. on cancer) before being integrated into a single funding programme for health.
The third health programme136 finances a range of collaborative projects across Europe around the three broad headings of health threats, health determinants and health information. However, the key point about the programme is its size, or rather lack of it; a budget of around €46 million a year equates to 0.000058% of publicly funded health expenditure in the EU,137 or around one half of one millionth part. Even if compared with only the preventive part of national expenditure (around 3%), the programme’s resources remain relatively
135 European Commission (2018). Press release: State of Health in the EU: more protection and prevention for longer and healthier lives. Brussels, European Commission, 22 November 2018.
136 European Parliament and Council (2014). Regulation (EU) No. 282/2014 on the establishment of a third programme for the European Union’s action in the field of health (2014–2020). Official Journal, 86:1–13; in general, see European Commission (2014). Health programme. Luxembourg: Publications Office of the European Union. Available at: http://ec.europa.eu/health/programme/policy/index_en.htm, accessed 4 July 2014.
137 Source for comparison figure of total public health expenditure: OECD (2012). Health at a glance: Europe 2012. Paris: Organisation for Economic Co-operation and Development; source for comparison figure of total EU GDP (2010 figure): European Commission (2014). Eurostat statistics. Brussels: Eurostat.
Available at: http://epp.eurostat.ec.europa.eu/portal/page/portal/eurostat/home/, accessed 4 July 2014.
tiny. This small sum means that the EU cannot provide most of what a health system does; it does not, and will never, have enough money to do so, and it will always be engaged in supplementary actions.
Despite this relative lack of resources, the health programme has been effective in sharing knowledge, supporting collaborations between countries and generating comparable data for benchmarking; such European projects have changed the direction of entire national health systems, such as in the case of cancer, by highlighting comparisons.138 They show a strong bias towards supporting capacity building, often among EU-level groups such as the Association of Schools of Public Health of the European Region, the European Federation of Associations of Dietitians, and conferences or research projects intended to identify and promote good practice. A mid-term evaluation found that the health programme excelled in promoting networking but appeared to distribute its projects rather thinly.139 Nevertheless, this limited volume of resources inevitably affects the scope for EU-financed action on health.
The Commission has proposed a major change for the future. For the upcoming period of the Multi-annual Financial Framework (2021–2027), the Commission has proposed ending the health programme as a separate funding stream and instead integrating it within the European Social Fund Plus (ESF+) as part of the European Structural and Investment Funds. This is more than an administrative reorganization; rather, it is likely to represent a fundamental shift in the EU’s support for health. On the one hand, it means that health objectives are formally and specifically included in the proposed ESF+, as regards both public health and health systems, which potentially marks a very substantial increase in the resources available for health at EU level. On the other hand, the actual amount of money specifically allocated to health is around €30m less than in the previous programming period, and the degree of influence of health actors on how this money is spent is likely to be much reduced. Although the Commission proposes mechanisms for “consultation” of health authorities, the actual decision-making regarding funding would be made through the processes for the ESF+ as a whole.140 At the time of writing, these proposals are still being considered by the Council and the new Parliament; their exact impact on the EU’s financial support for health will depend on how the tensions described above are addressed.
138 Briatte F (2013). “The politics of European public health data”, in Greer SL & Kurzer P (eds.). European Union public health policies: regional and global perspectives. Abingdon: Routledge, pp. 51–63.
139 Public Health and Impact Assessment Consortium (2011). Mid-term evaluation of the health programme (2008–2013). Bologna: Public Health and Impact Assessment Consortium. Available at: http://ec.europa.
eu/health/programme/docs/mthp_final_report_oct2011_en.pdf accessed 4 July 2014.
140 See COM(2018)382. Proposal for a Regulation of the European Parliament and of the Council on the European Social Fund Plus (ESF+), 30 May 2018.
3.6.3 Expert Group in Health System Performance Assessment Given the increased interest in monitoring EU Member States’ health systems and assessing their comparative performance, also in the context of the European Semester, the Commission in 2014 set up an Expert Group on Health Systems Performance Assessment (HSPA), consisting of representatives from all EU Member States (and Norway). The aim was to develop a common understanding on HSPA approaches, tools and methodologies, through sharing national experiences in this field. Experts from WHO, OECD and the European Observatory on Health Systems and Policies provide additional support and advice. Work so far has focused on how to assess performance in specific domains including quality, efficiency, primary care, integrated care and resilience.
3.6.4 Expert Panel on Effective Ways of Investing in Health
To ensure timely, scientific, non-binding advice on strategically relevant health matters, the European Commission set up in 2012 a multidisciplinary independent Expert Panel on Effective Ways of Investing in Health. Its overall aim is to make scientific contributions to the effectiveness, accessibility and resilience of European health systems.141 At the same time, the work of the panel acknowledges the contribution of public health and health systems to health and wealth in the European Union. This contrasts with mere cost-containment or austerity policies as promoted by other Directorates-general. The panel consists of 14 members who serve a three-year term. The panel has produced continuously a large number of opinions concerning, for example, digital transformation, cross-border care and vaccination.142
3.6.5 The EU Health Policy Forum
The EU Health Policy Platform is a consultation mechanism funded by the Health Programme, the largest and one of a long series of institutionalized consultative mechanisms organized by the health DG. It is an open platform, with over 5 000 members at the time of writing, ranging from the Brewers of Europe and the European Association of Sugar Manufacturers to the Irish Cancer Society and the Caritas of the Diocese of Coimbra in Portugal (to select from the 60 organizations attending its November 2018 meeting). Membership and engagement reflect an interest in health policy, not a stance, as seen in the presence of industry. It has a variety of activities, including an annual meeting, an award, and thematic groups that can formulate agendas to develop over a year, with participation voluntary and a presentation at the annual meeting. As with most of these consultative
141 Available at: https://ec.europa.eu/health/expert_panel/sites/expertpanel/files/rules_of_procedure_en.pdf.
142 All opinions are available online at: https://ec.europa.eu/health/expert_panel/home_en.
groups, it is a way for stakeholders, including poorly resourced ones, to maintain some contact with the Commission and each other and remain informed, and for the Commission to validate thinking and test out support for different policy ideas. Its importance varies with the importance the Commission assigns to it, which participants can easily monitor by, for example, seeing who participates from the Commission. It diffuses technical and political information, formally and informally, but its impact on policy or its members is unclear.
3.6.6 The Working Party on Public Health at the Senior Level
The Working Party on Public Health at the Senior Level is a Council working group which can provide input on behalf of ministers on a wide range of topics.
In the Semester it has a role in consultation on health recommendations. As a Council formation, its importance can vary with the presidency; for example, the 2018 Austrian presidency tended to call meetings only at the attaché level.