The path to a European Health Union

Summary

The European Union has historically left health policy decisions to individual member states, cooperating only on issues like cross-border healthcare and medicine safety. However, the COVID-19 pandemic underscored the need for collective action across borders. In response, in October 2020, European Commission President Ursula von der Leyen called for the creation of a “European Health Union”. This initiative aims to enhance the protection of European citizens' health, bolster pandemic preparedness, and strengthen healthcare systems. So far, the initiative has not led to major contestation. This might be because the proposals under this heading have been rather piecemeal and are not generally seen as being part of a comprehensive vision for identifying areas where EU intervention benefit national health policy. In this contribution we propose a path forward in terms of content and process for developing a more comprehensive vision on the policy content and the process. In so doing, we are not debating the need for a European Health Union. We take for granted that the existing European Health Union presents an opportunity to deliver, now and in the future, the added benefit of harmonizing, centralizing, or coordinating health-related laws, institutions, policies and actions at EU level.

Priority and choice

The EU's member states have long seen health policy as a matter for them to decide, working together only where there are obvious reasons to do so. Examples include cross-border care or the safety of medicines. They have retained national control over those aspects of health services that do not have a clear cross-border dimension, such as financing and delivery of care and workforce planning. The pandemic has changed this, as concerted action was required to combat a virus that disregarded national frontiers. In October 2020, European Commission President Ursula von der Leyen announced that: “We cannot wait for the end of the pandemic to repair and prepare for the future. We will build the foundations of a stronger European Health Union in which 27 countries work together to detect, prepare and respond collectively”.¹

This imperative is being translated into new legislation within the policy frame of a ‘European Health Union’. This includes a series of measures designed to enhance protection of the health of European citizens, strengthen the ability of the EU and its Member States to prevent and respond to future pandemics, and improve the resilience of Europe's health systems (Box 1).² Yet while all these measures are widely seen as a good start, we and others have argued that more is needed.3, 4, 5 For example, the European Patients Forum has argued that “the current proposal should be considered as a starting point to build better healthcare for the benefits of all Europeans”.⁶ A manifesto calling for a strong European Health Union based on solidarity, sustainability, security and inclusion has attracted almost 1500 signatures⁷ and a new book, co-edited by a former EU Health Commissioner and with contributions from leading health scholars, has set out a long list of opportunities.⁸

Box 1. What is the proposal for a European Health Union?

Who? The proposal for a European Health Union was first mentioned by Ursula von de Leyen, President of the European Commission in her 2020 State of the Union address. The idea was developed in a European Commission Communication.⁹

What? The proposal for a new ‘policy frame’ began as a call for strengthened coordination by the EU of responses to cross-border threats. Several legal proposals have been adopted under this heading: extending the remit of the European Medicines Agency¹⁰ and European Centre for Disease Prevention and Control,¹¹ creation of a new entity, the Health Emergency Preparedness and Response Authority (HERA),¹² additional investment in research and development, and creation of a European Health Data Space that will support the exchange of information. Other legislative proposals, such as the European Beating Cancer plan and a reform of pharmaceutical package¹³ have also been put forward as elements to be included. The latter includes measures seeking to make medicines more available, accessible, and affordable, while supporting the competitiveness of the EU pharmaceutical industry, as well as proposals to tackle antimicrobial resistance.

When? The proposal for a European Health Union was first made in 2020 but the documentation does not specify an implementation term or envisage a fixed end date when it should have been achieved.

Looking ahead, European governments face many challenges. The next pandemic could be much worse and, as extreme weather events in Europe in 2023,¹⁴ shortages of health workers, and problems with access to medicines remind us, there are many other threats. So how can governments take advantage of the opportunities provided by the European Health Union and what should be the next steps in realizing President von der Leyen's commitment?

A true European Health Union will require an ambitious vision, just like that which inspired the European project in the 1950s when Europe was recovering from the devastation of a World War II. The shock caused by COVID was on a vastly smaller scale, but it could have been much worse. The original European idea was led by a few individuals, such as Jean Monnet,¹⁵ but the world has moved on. The Europe of the future must draw on a wide and diverse range of perspectives and give voice to those who might otherwise be unheard. This, in our view, calls for the health community to engage proactively, making the case for change and offering evidence-based solutions based on the values that underpin public health. This health community has shown that it can come together, despite the relative powerlessness of the national health ministries,¹⁶ to challenge policies that threaten health.¹⁷

Doing so is not, however, easy: When those with an interest in health come together, including those who direct, pay for, provide, and benefit from health measures in their broadest sense, they typically bring their own interests and expectations to the table. Many want to ensure that ‘their’ disease, population, or professional group is mentioned explicitly in any new strategy. The result, too often, is a shopping list. This creates problems. First, there will always be some diseases, populations, or professions that are not mentioned, encouraging those excluded to create a coalition to attack the overall strategy. Second, it encourages the silo working that is the opposite of what is needed to address the complex interlinked health issues that we face today.

What is the alternative? How can we decide what the remit is, or should be of a ‘European Health Union’ besides a series of legislative measures that are not logically and necessarily connected with one another? What are our priorities and what choices must we make?

We propose a two-stage approach that considers policy content and then process (Box 2). To be clear, we are not debating the need for a European Health Union. We take for granted that the existing European Health Union presents an opportunity to deliver, now and in the future, the added benefit of harmonizing, centralizing, or coordinating health-related laws, institutions, policies, and actions at EU level. Even more importantly, we see the vision enshrined in the commitment to a European Health Union as something that, in a Europe where our senses of solidarity and belonging, including those we care about and want to care for, are still largely bound up in nationality, can give form to our sense of ‘Europeanness’. This recognizes our pragmatic need for solidarity and protection of human dignity in the face of disease and death that comes from being a neighbour, even if this connection is weaker than within our national borders. It is with this vision in mind that choices must be made as to what we do together and what we do ourselves.

Box 2. Key messages.

The European Health Union, a series of initiatives developed by the European Union in response to the pandemic, will make a important contribution to protecting and promoting the health of Europe's citizens. However, it is still work in progress and, if it is to achieve its goals, it must:

• a)Develop a shared, comprehensive, and coherent vision of the many present and future threats to the health of the people of Europe;
• b)Create a policy process that is inclusive, ensuring that those responsible for health in member state governments have a voice in decisions that affect them and that engages fully with a wide range of other actors, including civil society and other international agencies such as WHO.

Step one: a shared vision on policy content

Our first step involves agreement on a vision of the functions and content that a European Health Union should have. This means moving away from the smorgasbord of demands from interest groups to agree on a comprehensive framework that brings together the many interconnected threats to health in the EU that act across many sectors and levels, asking where the EU can bring an added benefit to health policy at national level? It also means identifying where health measures contribute to the achievement of the central objectives of the Union itself.¹⁸

What are the cross-cutting health challenges in the EU?

We see the report of the Pan European Commission on Health and Sustainable Development, written for WHO Europe, as offering a blueprint that can be used in a stocktaking of what we can expect to be the central needs and challenges for all public health and health systems in the EU.¹⁹

This has, at its centre, the concept of One Health. This recognizes the importance of the interaction between the health of humans, animals, and the natural environment, all influencing and being influenced by ubiquitous micro-organisms. The EU, given its much stronger roles in agriculture and the environment than in health, combined with its normative and regulatory powers, has clear potential for delivering added benefits when addressing One Health challenges.

It also emphasises the ‘social determinants of health’; those areas where governments, acting individually or collectively, can safeguard and promote health. Examples include enabling investment in education, employment, housing, or health services and reducing threats to security, including those arising from war and conflict. It also includes helping public institutions to address the ‘commercial determinants of health’, both positive and negative. Examples include tackling the proliferation of health-damaging products and investing to improve digital access.

The EU has legislative powers that can either promote or undermine health by addressing these issues. We argue that, when they are examined through the lens of health determinants (as opposed to, for example, trade or the internal market), it will become clearer whether the EU should or should not take action to harmonise national policies. For example, seen through a health lens, the case for opening national health systems to greater competition would arguably undermine the concept of national solidarity that underpins access to health care, and likely not be supported, calling for maintenance of the status quo.

Last, it will be important to identify health measures that can contribute to the achievement of the objectives of the Union itself.¹⁸ These include achieving sustainable development and social progress, promoting social justice and protection, promoting scientific and technological progress, and combating social exclusion and discrimination (Article 3 of the Treaty on European Union). Increasing understanding of what are termed co-benefits, whereby health policies help achieve policies in other areas, such as healthier populations contributing to economic growth, have expanded recognition of the opportunities that exist.²⁰ Again, by looking through a health lens, it becomes easier to see where tensions may arise between the objective to protect ‘mainstream’ health in all EU policies and the threats to health that may derive from EU activities in other sectors, for example in trade agreements where there is pressure to weaken safeguards affecting food, agriculture, or environmental protection.

Step two: a policy process for strengthening the involvement of the national health community

If a broad vision on the functions of a European Health Union can be agreed, we should bring the expertise, knowledge, and representation that is available in the European health community into the process of developing it, either in the legislative process or in shaping its implementation. Here we argue that form should follow function. Two issues must be addressed.

The first relates to where health-related policies are made? Health ministers and officials from member states meet within the framework of the Council of (Health) Ministers but discussions are limited to a few areas. Governments have given the EU strong and sometimes exclusive powers in areas such as agriculture, competition, and trade but many fewer powers to act on health.²¹

Address the weakness of existing arrangements for national health representation

When there is agreement that action is needed to protect or promote health, the relevant measures will often be taken by other groups in the Council of Ministers and EU Parliament groupings, in some cases being initiated by another Directorate General (DG) in the European Commission rather than the DG for health. A famous example is the ‘Bolkenstein Directive’ in which the EU was aiming to harmonise all national laws related to provision of services, including health services. This legislation was initiated by DG MARKT, and could have resulted in very large-scale reforms of all national health systems.²² The health community was stunned by the proposal, and it was eventually brought to a halt. Yet there are many other examples of where ministerial and other institutional groupings within the Council, the Parliament, or the Commission engage with health laws and policies on issues that, if discussed at a national level, would have fallen within the purview of health actors.

This compounds the already relatively weak position of the health ministry vis-à-vis other ministries within countries¹⁶ and the related political representation of health vis-à-vis other societal objectives, reducing its ability to exert meaningful influence. It will thus be necessary to find ways to strengthen health input into EU discussions that impact health. One way to do this is by creating a stronger EU legislative basis, including a shared competence for adopting health law and policy at EU level. This would likely strengthen the involvement of national institutions in health debates at EU level, given the nature of the EU legislative process (Article 294 Treaty on the Functioning of the EU).

Even if such a Treaty change is not realized, the issue of who has a seat at the table can still be addressed through institutional changes. Health issues are scrutinized by the European Parliament, but in a committee that combines the environment, public health, and food safety. The creation of the European Health Union would suggest that health have a committee of its own, also the national representatives in the Council could meet more often and in a more concentrated health grouping. This could provide a means to scrutinize initiatives in other sectors that impact health. However, there is also a case for strengthening the role of civil society organisations. With a few exceptions, these have limited visibility at the European level. Yet they can act as an important resource for legislators seeking to understand the often complex effects of what they are enacting. In their absence, the door is open for powerful vested interests, including those whose products threaten health, to set the narrative and provide their own version of the evidence required to understand the issue.²³ However these civil society organisations struggle to be heard so it will be important to find better ways to engage them in the policy process and to provide continued support for their work, such as the operating grants available within the EU4Health programme.²⁴

The second issue is to ensure synergy with the work of the World Health Organisation, particularly its regional office. Here 27 Member States of the 53 that are within the European Region are in a ‘double bind’ in that they are bound to cooperate within WHO structures, and through the EU. At the same time, EU internal health policies and laws are increasingly also impacting global health explicitly through activities in trade and development, and often implicitly through, for example, the ‘Brussels effect’.²⁵ The central question here is given current arrangements for coordination and cooperation within this bloc of 27 countries in the field of health, what should the EU's role should be in the global health architecture. As with the European Health Union itself, the EU's recently published global health strategy is seen as a good start but with many questions unanswered.⁴ Among them is the question of how to reconcile differing views of global issues where national interests differ. The challenges of maintaining a consistent approach have been highlighted by events in Ukraine and in Gaza, but they also include aspects of trade policy, with divisions between those with and without large pharmaceutical sectors.

Conclusion: more than a promise

The European Health Union as a policy ideal to rally around is a promising step forward and addresses some of the weaknesses revealed by the pandemic. However, resilient, and healthy populations are not achieved by policy frameworks emerging from crises and emergencies alone. If a European Health Union is to be more than the sum of its parts, it must be based on a clear vision on the functional benefit the EU can deliver for the health of people living in Europe. Furthermore, there needs to be a form and process that engages the wealth of health expertise and knowledge available at Member State level that can help realise this vision. If we are to address the challenges ahead for human health, in Europe and the world, we need to engage in ways that ensure that we have health politics and policy-making processes that go beyond the health sector and national borders.

Contributors

Both authors contributed equally.

Declaration of interests

MM is Research Director of the European Observatory on Health Systems and Policies, in which the European Commission is a partner, and holds research funding from the European Commission's DG RESEARCH and was a Commissioner on the Pan European Commission on Health and Sustainanble Development. AdR has nothing to declare.