The COVID19 outbreak has had two political consequences for the European Union: it has put closer integration of EU internal health activities on the agenda, and it has pulled the EU in a leading position on global health policy. The present call for a European Health Union by the European Commission brings an important political opportunity for the geopolitics of global health as its internal legal and political capacity for health immediately interacts with the EU's capacity to strengthen global health. It is still the case that the EU can only act externally to the extent that internally it has the competence to do so [1,2]. Yet given the present geopolitical pull on the EU to play a role in global health, this will also benefit the Member States internally.
In the course of 2020 the EU – in close cooperation between the Council presidencies and the Commission - has moved to politically support the World Health Organization in the face of the US attacks, launched pledging conferences for vaccine development and distribution and has most recently proposed an ‘international pandemic treaty’ to prevent future global disease outbreaks and better coordinate a worldwide response. It is also preparing a major global health conference together with the G20 Presidency (Italy) to take place in May 2021.
Besides these obvious activities, the EU's role in global health has many dimensions, that are not always clearly recognized in the global health debate [3,4]. There are many complex governance mechanisms, technocratic and regulatory influences, and financial flows that play a role in this regard. Hence, in wanting to shape a strong EU role in global health it would be too narrow to only look at those activities labelled ‘health’. Rather, we need to take into consideration also the impact the EU can have in say, its trade policy, in – for instance – tackling determinants of health. Another site for impact is the commitment to a European Green Deal where in its internal policy the EU can play an important norm-setting role in global health, particularly in the area of trade.
In this regard, the EU has the ability to ‘wield significant, unique, and highly penetrating power’ (‘The Brussels Effect’) through setting standards [5]. This applies to setting safety standards that impact global health, in areas such as food safety, chemical safety, environmental policies and more recently also digital health [6]. Internally the EU has the obligation to protect public health through article 168(1) Treaty on the Functioning of the EU (TFEU) and Article 9 TFEU [7]. Both are aimed at the protection of a high level of (public) health in all EU policies and regulation, which includes the EU's external policies. Hence, the possibility for the EU's global impact improves, where the moral and economic imperatives of the Union coincide.
Besides the trade route, the EU remains the largest development donor. However, the internal-external link is much less strong here, and Article 208 TFEU only holds a complementary competence for the EU vis-a-vis the development programmes of its Member States. We now see that Overseas Development Aid (‘ODA’) is threatened through the pandemic and for ensuring common goods such as COVID19 vaccines, new forms of financing are needed. This means that the EU would need to revisit its approach to development finance; in the context of the G20, as well as its approach of ‘fourth wave’ trade agreements. In these newer types of trade agreements, increasingly external health policies are included that link the ‘soft’ development agenda with trade, as part of hard competitive growth factors [4].
Another site for a stronger EU role in global health is in EU security law and policy. Health here is now seen as a ‘transboundary security issue’ that creates a nexus between internal and external and CFSP-TFEU security policy [2]. This ‘security’ angle might promise a stronger EU role in global health particularly also alongside the United States. What may come of this will remain critical as the proposal for a pandemic treaty is taken forward.
As the internal-external nexus determines to a large extent the EU's ability to lead in global health, the internal discussion on a European Health Union is of pivotal importance. Here the potential of a more extensive interpretation of the current internal EU competences on health (Art. 168 TFEU) will affect the scope of Article 207(4)(b) TFEU which prescribes that when it comes to trade, health services (but not public health) are subject to unanimous voting in the Council. COVID19 has shown that the division between redistributive health care policy (where EU powers are very limited) and public health, is difficult to maintain: the high relevance of medical supply chains, the joint procurement of COVID19 vaccine, medicines and diagnostics as well as the need to make available hospital beds and funds to prop up hard hit health care systems in Member States are some indications of why change might be in the air.
From January 2021 the Portuguese Presidency will need to focus on where the EU's internal role in health can be strengthened, so as to ensure a stronger role externally. The current proposal of the European Commission to create a European Health Union in response to the coronavirus outbreak has focused on outbreak preparedness and response, but a much more encompassing approach will be needed. This is difficult because the capacity for global health at EU level, both in the institutional make up and in its external action is still limited. As more far-reaching proposals are made for Member State cooperation and expansion of the EU’ s role internally, these proposals need to be matched by a strong and renewed EU agenda for global health.
Author Contributions
IK and AdR contributed equally.
Declaration of Interests
IK and AdR have nothing to disclose.
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