Health and health policies in the European Union
Professor, Global Health and Development, University of Tampere
Online publication Future of Europe
© SOSTE Finnish Federation for Social Affairs and Health, February 2019
Cooperation between member states, the Commission and NGOs focusing on public health has been promoted through the EU Health Programme. The programme, however, is currently under review. It is expected that EU level control over the allocation of funds will increase, while the role of member states is expected to decline. This poses new challenges for both national and EU level health policies. While there are promises of improved consideration of health under other directorates, there is a danger that health policies and health systems become governed and driven by other policy priorities.
Formal health policy enacted under the EU Commission’s Directorate-General for Health and Food Safety has been based on public health policy under Article 168 of the Lisbon Treaty, which falls under the so-called supporting competence. The decision-making power of the member states is primary, and EU measures complement these. In practice, national health policies are affected not only, by the EU Health Programme and the policy measures implemented under it, but also by the challenges arising from other policies, the single market and in particular economic policy.
European Union activity on health issues may be divided into i) measures taken under the Directorate-General for Health and Food Safety (DG SANTE) and the Health Programme ii) requirements of the single market, iii) issues falling within the European Semester, iv) requirements and actions arising from other jurisdictions and Directorates and v) global health issues and external competence.
Health Programme and DG SANTE
The European Union Health Programme in its present form is expected to be closed. It has not required a great deal of funding – a total of 449.4 million euros was reserved for it during 20142020 – but it has served to maintain cooperation between member states, the Commission and NGOs promoting public health. In addition, it has provided a channel for member state’s ministries of health to network, influence and contribute to how the European Union relates to health issues. Funding has been channelled, for example, through mutually financed joint action projects on health promotion and protection. Cooperation and activities conducted under the Health Programme are likely to continue with funding from the European Social Fund, but the decision-making power of the Commission and the EU in the distribution and allocation of these funds will increase. In the future, the importance of the member states in the allocation of funds is likely to decrease, and EU level steering is likely to increase. The future of the Directorate-General for Health and Food Safety (DG SANTE) is also unclear; it will continue as a separate Directorate-General or it will be placed entirely or partially under another Directorate-General. There is a history of transferring obligations between Directorates. For example, issues related to medicines have been moved to DG Sante from the single market, and consumer issues have been shifted from DG Sante.
In the future, the importance of the member states in the allocation of funds is likely to decrease and the Union level steering is likely to increase.
The reasons presented for closing down and transferring the Health Programme to the European Social Fund are somewhat contradictory: it has been argued that in the future, the European Commission will pay more attention to health in all of its policies. This reasoning is repeated in the emphases of both the conclusions of the Presidencies and Council and the obligations of the Treaty to secure a high level of health protection in all policies. What makes it paradoxical is that effective actions will be harder to undertake, if there is less capacity in public health within the Commission and if the critical mass and connections to the Ministries of Health in the member states deteriorate. Such an approach could create a situation where the views of healthcare lobbyists, firms and big Directorates become more prominent in defining health policies in the European Union. This is significant due to concerns over the sustainability of healthcare financing on the one hand, and the significant commercial interests of pharmaceutical and other health-related industries on the other. This may be particularly apparent, for example, with respect to European Union policies and decision-making on regulatory cooperation and principles, data exclusivity and intellectual property rights and pricing of medicines, orphan drugs, vaccines, health technology assessment (HTA) and other health services or health data related commercial policy and regulatory issues.
In addition, consideration of the extent to which shifts between the Directorates will affect the transfer of powers between member states and the European Union has to be examined. Furthermore, it is necessary to anticipate what it will mean in the longer term to health policy institutions and actors under the European Union. The European Medicines Agency operating under the auspices of the EU is located in Amsterdam. Its task is to guarantee the scientific evaluation, supervision and safety of human and veterinary medicines. The European Centre for Disease Prevention and Control (ECDC) is in Stockholm and focuses on strengthening Europe’s defences against infectious diseases. The European Food Safety Authority (EFSA) operates in Parma while both the European Agency for Safety and Health at Work (EUOSHA) in Bilbao and the European Chemicals Agency (ECHA) in Helsinki are active under other Directorates. These agencies are responsible for common health protection standards and monitoring of public health and health security across the European Union.
The EU Health Programme has supported the public health programmes and cooperation in the member states, but its role has been expanded to include cooperation relating to health services. via the Directive on the application of the patients’ rights in cross-border healthcare. Because of the likely termination of the Health Programme and the transfer of its funding to the European Social Fund, the role of the Directorate-General for Employment, Social Affairs and Inclusion (DG EMPL) is likely to increase, although it already handles many issues relating to healthcare systems such as long-term care. The Commission has also established a high-level steering group and a separate expert group to reflect upon issues relating to the promotion of health, prevention of diseases and non-communicable diseases as well as to produce opinions for the use of other sectors and for the European Semester process. The reform of DG Sante, as well as other attempts to place new opportunities partially or primarily under the single market would suggest, that an underlying aim is to affect the balance of power between the Commission and member states.
Health issues related to the single market
In the single market, the powers of the EU are more straightforward than in public health issues, but this can distort policy priorities and purpose in health –related issues. The new measures on health technology assessment (HTA) as well as competence for it have been set primarily under the single market. From the viewpoint of the pharmaceutical industry and vaccine producers, the single market is the easier environment. In addition to actions clearly related to health, several other openings, which are significant for health and health-related services are governed under the internal market. These include the mobility of healthcare workers, data protection and IT issues, orphan drugs, exclusive rights and competition within the field of pharmaceutical policy, product labelling, and issues relating to competition and state aids.
The future questions of the internal market policy also include standardisation. Standards and the role of standardisation organisations is also on the trade policy agenda of the EU. However, attempts to expand the significance of standardisation activities in the internal market to health has also been criticised e.g. by European medical associations.
The attempts to expand the significance of standardisation activities in the internal market to health has also been criticised e.g. by European medical associations.
The commercial service providers in the healthcare sector have criticised state aid provided to public service providers, and the effects thereof for the position of for-profit and non-profit services providers and different types of undertakings in the internal market. Complaints have also been made e.g. on the application of the EU Directive on patient’s rights in cross-border health care in Finland and whether the Finnish tax on sweets complied with EU competition rules. Companies and interest organizations may use complaints as a means of expanding their market share, limit the leeway of public and non-commercial operators, or to influence the legislative decision-making and measures.
The question as to what extent the Finnish social and healthcare reform and its obligations can lead to the expansion of marketization is not unfounded, as the interpretation of services of general interest outside the single market obligations is narrow. Public procurement and related obligations are also dealt with under the single market. However, Finland has also applied public procurement obligations more extensively than is required and even anticipated future obligations, often more broadly, than what the EU single market obligations would require.
The European Semester is connected to the 2008 economic crisis, but requirements of the common currency and economic integration set the broader context of Semester process. European Semester process competence is with coordination of economic policies, which relates to how and to what extent obligations may be imposed on member states. The bigger the economic policy problems, the bigger the power used by the Commission. However, social protection and health systems are important for the European Semester because of their major budget share. The sustainability of financing of health systems in Member States has been put under special examination, and even though cost-efficiency is stressed in the recommendations of the Commission, goals have been set primarily by the Ministries of Finance.
Even though the competence of the European Semester arises out of the economic policy coordination, the recommendations have reflected other goals of the European Union as well, particularly to the extent that they have remained unfinished at the national level in the member states. The content of social and healthcare policies are also discussed under the Social Protection Committee. An Expert Panel on Ways of Investing in Health (EXPH) has been established to consider efficient ways of investing in health, including challenges arising from the Semester and the single market. The Semester in its current form strengthens economy-driven technocratic policy within European Union, as decision-making takes place under economic policy framework and considerations.
Health in other policies
In addition to the single market and the Directorate-General for Employment and Social Affairs, health issues are strongly part of other Directorates, e.g. the Directorate-Generals responsible for agriculture, research and industry. Agricultural subsidies and incentives have become a major issue due to their considerable financial share and the importance to nutrition and food policy for health. EU research programme channels funding and affect the basis and allocation of health-related research in the member states. European Union research programme has also expanded to funding of development and innovation, e.g. on pharmaceuticals and healthcare technology. European Union role and activities under environmental policy have relevance to environmental health and particularly in how environmental change, antimicrobial resistance, air pollution, health risks of pesticides and endocrine disruptors are taken into consideration in the EU policy and regulatory activities.
In addition to DG Sante, the Directorate-General for Employment, Social Affairs and Inclusion (DG EMPL) has traditionally had a prominent role in issues relating to health and safety at work and social protection. The European Semester and the increasing importance of the European Social Fund may also mean a bigger role for DG EMPL. The Pillar of Social Rights and obligations arising from these rights are likely to be reflected more strongly in health policy as well. It is also possible, that the Pillar of Social Rights becomes the last safeguard against budgetary pressures and other policy priorities for member states, the Commission, and requirements set as part of commercial policy, and the Semester process.
The European Semester and the increasing importance of the European Social Fund may also mean a bigger role for DG EMPL.
External competence, trade and global issues of development cooperation
The external competence of the European Union in health issues is limited to funding, cooperation and coordination of the views of the member states as regards the World Health Organisation (WHO). Unlike in trade policy, where the Commission represents the Member States in negotiations and the World Trade Organisation (WTO), in WHO the decision-making has been more strongly in the hands of the member states. Global health issues have already been addressed in Council conclusions on global health and under the Commission’s global health framework. European Union role in global health has also influenced development cooperation and security issues linked with health.
The importance of the European Union for public health and health systems is reflected increasingly through influence of policies defined under other policy sectors and the single market. Emphasis on addressing Health in All Policies will remain empty words in the EU, if there is no critical mass and knowhow to take this effort further. In the single market, new obligations and openings favouring lobbying and prioritisation of commercial policy interests, raise also new challenges for sustainability of health systems financing. This is important, in particular, for European measures with relevance to pharmaceuticals and medical devices, incentives for innovation and regulatory principles and cooperation under commercial policy. For healthcare organisations, the new situation is demanding, both regarding the contents and monitoring and understanding of the overall picture. Emphasising national competence in public health or health promotion does thus not necessarily prevent the growth of influence and competence of the European Union through other policies and Directorates.
This is an article of the online publication Future of Europe.
© SOSTE Finnish Federation for Social Affairs and Health, February 2019