EU4Health, a €5·1 billion project spurred by the COVID-19 pandemic, aims to strengthen the response to health crises and challenges across Europe. Udani Samarasekera reports.
EU4Health, the EU's ambitious health programme for 2021–27, has become a reality, coming into force on March 26. Dedicated funding of €5·1 billion has been agreed for the project, which aims to protect citizens from cross-border health threats, make medicines more accessible and affordable, and build resilient health systems in the EU.
The programme is the EU's response to the COVID-19 pandemic, the biggest challenge it has faced since World War 2. As of March 18, the 27 countries of the EU have reported more than 23 million cases of COVID-19 and over 560 000 deaths, according to the European Centre for Disease Prevention and Control (ECDC). EU health systems, including those of well resourced member states, have struggled to deal with the crisis. “Only a common, joint approach will help us tackle such cross-border health threats”, Stefan de Keersmaecker, spokesperson for the European Commission, told The Lancet. The proposal for the EU4Health programme states that it will support new actions to “fill in gaps that this pandemic has revealed in terms of the development and manufacturing of medicinal products, the adequate supply of equipment in hospitals and sufficient medical human resources, the uptake of digital tools and services that enable continuity of care, and the need to maintain access to essential goods and services in times of crisis”.
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EU4Health funds will go towards creating a strategic reserve of medical supplies and of health-care staff and experts that can be mobilised to prevent or respond to health crises throughout the EU. “Building reserves should allow us to better tackle future pandemics”, says de Keersmaecker. The money will also support the training of health-care professionals for deployment across the EU and increased surveillance of health threats. Beyond preparedness and response, another key area of focus will be strengthening the health systems of the different member states, including investment in health promotion and disease prevention and improving access to health care. “We need resilient health systems that are well equipped to tackle new health challenges”, de Keersmaecker notes.
Health experts have welcomed EU4Health. Walter Ricciardi, professor of hygiene and public health at Catholic University of the Sacred Heart (Rome, Italy) and president of the World Federation of Public Health Associations, said: “This is a very important programme. It's the first time ever that the European Commission has tried to work in a concrete manner with member states, providing collaboration and support for health challenges. It is something we as a public health organisation have been advocating for years…Health nowadays is global, and decisions have to be taken at international level, but at European level you have to be at least coordinating your policies if not harmonising them.” François Alla, professor of public health at the University of Bordeaux, France, agrees: “It is essential to build a collective strategy to respond to global crises and challenges. Health must be a priority in this European strategy. This was not the case until now. I therefore welcome this initiative.”
The biggest advantage of the policy, Ricciardi says, is its potential to reduce health inequalities. “Europe is the continent where the highest health inequalities happen. Reducing inequalities and granting equitable [health-care] access to citizens is the most important result that can come from the European approach.”
EU4Health is the fourth and the largest of the EU health programmes in monetary terms since their inception in 2003. Its funds are more than ten times that of its predecessor. “I think the fact that it's a lot better resourced than the last health programme is very encouraging”, says Sascha Marschang, acting secretary general of the European Public Health Alliance, which represents more than 80 public health non-governmental organisation (NGO), patient group, and health professional members. Commenting on the proposal, he said: “In terms of the language and declared comprehensiveness of the communication, I think that that's pretty good. The thing of course is what does it mean in practice. For example, health inequalities—it's meant to be a general objective of the EU4Health programme, and it's also mentioned as a specific objective. But then when you look at the list of actions, when you are looking for things related to health inequalities it's a little bit less clear; it doesn't really translate into very tangible actions.”
de Keersmaecker notes that EU4Health will also help fund the policy priorities under the Commission's vision for a European Health Union, announced by Ursula von der Leyen, president of the European Commission, in her State of the Union address in September, 2020. Cancer is one such priority. €1·25 billion of EU4Health funding will go to Europe's €4 billion Beating Cancer Plan, which aims to tackle the entire disease pathway, with ten flagship programmes spanning from prevention to the quality of life of patients and survivors. Marschang says the plan is “very comprehensive”, but “what we want to avoid is falling into the trap of a siloed approach. That we only look at cancer, that we forgot about all the other non-communicable diseases. That we only look at pandemic preparedness, but we forget about the syndemic, the conditions that are creating the pandemic in the first place.”
As part of its European Health Union concept, the Commission is also establishing a new agency, the Health Emergency Preparedness and Response Authority (HERA). “What we do not have is what our American friends have, the so-called BARDA, this authority that allows the Americans to intervene quickly when a pandemic hits, by building reserves of medicines, reserves of medical devices, by immediately contacting the pharmaceutical industry, by testing production capacity, by immediately placing orders. This is why we suggested HERA”, de Keersmaecker explains. Ricciardi welcomes this new agency and the fact that “new power is going to be attributed to ECDC and EMA [European Medicines Agency], which are important bodies” in the implementation of the EU's health priorities. ECDC's mandate will be revised so that it can support the Commission and member states in several areas, including integrated systems to allow real-time epidemiological surveillance and preparedness and response planning, reporting, and auditing. EMA's mandate will be reinforced so that it can facilitate a coordinated EU-level response to health crises by monitoring and mitigating the risk of shortages of critical medicines and medical devices, providing scientific advice on potential medicines for diseases causing crises, coordinating studies to monitor the effectiveness and safety of vaccines, and coordinating clinical trials.
Digital transformation of health systems is another funding focus for EU4Health. Marschang notes that the pandemic has provided an opportunity to scale up digital health because many patients and health professionals in Europe needed to use electronic health and mobile health tools for the first time. However, he thinks that health literacy initiatives need to be clearly defined in EU4Health to avoid widening inequities. “Many of the groups who may not enjoy the best quality of health care tend to be the people that are less health literate. They then have issues using the technology and having access to the technology and most of all making sense of the information they find online.” Training for health-care professionals “so they can also work more effectively with patient communities around this issue of the digital transformation of health care” will be key and needs more clarity in EU4Health, Marschang says.
Member states, health organisations, and NGOs will be able to apply for EU4Health funding this year following the adoption of the 2021 work programme, which will prioritise crisis preparedness, disease prevention, health systems, digitalisation, and cancer. However, Anniek de Ruijter, associate professor of health law and policy at the University of Amsterdam in the Netherlands, is worried about the bureaucracy of the funding distribution process. “This is an opportunity to really display the EU-added benefit for alleviating some of the inequalities in access to high-quality care across EU member states. Now there will be this whole bureaucratic circus of calls and applications for calls. Would that effort not be better spent if at least a big chunk of the funding is disseminated in direct contact with national public health authorities?”, she asks.
de Ruijter is also concerned about the governance of the programme. Although the EU4Health proposal mentions monitoring, reporting, evaluation, and auditing, she questions “how much capacity does the EU actually have here to do the monitoring and auditing in the member states itself?...These things are not at all in a clear form” in the proposal. “I'm just worried that a lot of money will go out, but there's not enough capacity to do the governance part of it.”
Additionally, Marschang raised concerns about long-term follow-up. “The problem is, if I think about some of the calls that were released under the previous health programme, the projects themselves might have been good, and the output excellent as well, but then are these outcomes being integrated into national health systems or do they then become forgotten about over time?”, he comments. “When you have European projects, there's a lack of follow-up or lack of money for the national health system to integrate these best practices, these ideas, practically into their health system because their health system might be a slightly different model to the country that was leading on the project.”
Ricciardi thinks that delivery and implementation are the crucial focuses now. “At the moment, with the money that has been allocated, it is more than enough to start working and provide concrete results for citizens”, he says. However, he acknowledges, “This is a very complex programme. The challenge now is governance and implementation.”