European support for improving global health systems and policies

European support for improving global health systems and policies POLICY BRIEF 57 Scott L Greer Nicole Mauer Holly Jarman Olivia Rockwell Michelle Falkenbach Ilona Kickbusch Dimitra Panteli Matthias Wismar HEALTH SYSTEMS AND POLICY ANALYSIS Keywords: Health Policy European Union Intersectoral Health strategy Global health goals This policy brief is one of a new series to meet the needs of policy-makers and health system managers. The aim is to develop key messages to support evidence-informed policy-making and the editors will continue to strengthen the series by working with authors to improve the consideration given to policy options and implementation. What is a Policy Brief? A policy brief is a short publication specifically designed to provide policy makers with evidence on a policy question or priority. 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The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. The views expressed by authors, editors, or expert groups do not necessarily represent the decisions or the stated policy of the World Health Organization. Editors Scott Greer Nicole Mauer Matthias Wismar Managing Editors Jonathan North Lucie Jackson The authors and editors are grateful to the reviewers who commented on this publication and contributed their expertise. Contents page Acknowledgements 2 Acronyms 3 List of tables, figures and boxes 5 Key messages 6 Executive summary 7 Policy brief 8 Part I: Understanding EU Global Health Policies 8 1. Introduction 8 2. Evolution of EU global health strategies 9 3. Competencies and structure 12 4. Prioritization 14 5. Places 18 6. Conclusions 20 Part II: Mapping EU global health policy 21 1. Trade in goods and services 21 2. Public investment and fiscal instruments 24 3. Official development assistance and humanitarian aid 27 4. Solidarity, voice and multilateralism 33 5. Research and training partnerships 40 Bibliography 43 Annex: Mapping of policy areas and instruments 52 Authors Scott L Greer, European Observatory on Health Systems and Policies and University of Michigan, Ann Arbor, United States Nicole Mauer, European Observatory on Health Systems and Policies Holly Jarman, University of Michigan, Ann Arbor, United States Olivia Rockwell, University of Michigan, Ann Arbor, United States Michelle Falkenbach, European Observatory on Health Systems and Policies Ilona Kickbusch, Graduate Institute of International and Development Studies, Geneva, Switzerland Dimitra Panteli, European Observatory on Health Systems and Policies Matthias Wismar, European Observatory on Health Systems and Policies European support for improving global health systems and policies Print ISSN 1997-8065 Online ISSN 1997-8073 2Policy brief Acknowledgements We would like to thank Isabel de la Mata, Josep Figueras, Marion L’Hote, Suszy Lessof, Francisco Pérez-Canado and Zoltan Somogyi. 3European support for improving global health systems and policies Acronyms ACT-A Access to COVID-19 Tools Accelerator AfT Aid for Trade AIDS acquired immunodeficiency syndrome AMA African Medicines Agency AMR antimicrobial resistance CDC Centres for Disease Control and Prevention CEF Connecting Europe Facility CEPI Coalition for Epidemic Preparedness Innovations COVAX COVID-19 Vaccines Global Access CSD Civil Society Dialogue DG Directorate General DG AGRI Directorate General for Agriculture and Rural Development DG CLIMA Directorate General for Climate Action DG ECHO Directorate General for European Civil Protection and Humanitarian Aid Operations DG ENV Directorate General for Environment DG GROW Directorate General for Internal Market, Industry, Entrepreneurship and SMEs DG INTPA Directorate General for International Partnerships DG JUST Directorate General for Justice and Consumers DG NEAR Directorate General for Neighbourhood and Enlargement DG SANTE Directorate General for Health DG TRADE Directorate General for Trade EBRD European Bank for Reconstruction and Development ECB European Central Bank EDF European Development Fund ECJ European Court of Justice ECDC European Centre for Disease Prevention and Control EDCTP European and Developing Countries Clinical Trials Partnership EEA European Economic Area EEAS European Union External Action Service EFSA European Food Safety Authority EFTA European Free Trade Association EFSD European Fund for Sustainable Development EFSD+ European Fund for Sustainable Development Plus EHRC European Humanitarian Response Capacity EHU European Health Union EIB European Investment Bank EMA European Medicines Agency ENI European Neighbourhood Instrument EU European Union FAO Food and Agriculture Organization FCTC Framework Convention on Tobacco Control FIF financial intermediary fund FPI Foreign Policy Instruments GATS General Agreement on Trade in Services GAVI Global Alliance for Vaccines and Immunisation GDP gross domestic product GDPR General Data Protection Regulation GSP Generalised Scheme of Preferences (standard) GSP+ Generalised Scheme of Preferences (special incentive arrangement for good governance and sustainable development) H4AP Health for All Policies HAB Humanitarian Air Bridge HERA Health Emergency Preparedness and Response Authority HiAP Health in All Policy HIV human immunodeficiency virus HSRC Health Systems and Response Connector HSS health system strengthening ICC International Criminal Court IHR International Health Regulations ILO International Labour Organization IMF International Monetary Fund IOM International Organization for Migration IP intellectual property IPA Instrument for Pre-Accession Assistance (first generation) IPA III Instrument for Pre-accession Assistance (third generation) IPR intellectual property rights LDC least developed countries LMIC low- and middle-income countries MAV+ Manufacturing and Access to Vaccines, Medicines and Health Technologies MDG millennium development goal MediPIET Mediterranean and Black Sea Programme for Intervention Epidemiology Training MFF multiannual financial framework MIP multiannual indicative programme MoU Memorandum of Understanding NDICI neighbourhood, development and international cooperation NGO non-governmental organization ODA official development assistance OHCHR Office of the UN High Commissioner for Human Rights PPR prevention, preparedness and response S4D4C Using Science for/in Diplomacy for addressing global Challenges SDG sustainable development goal SEAR Solidarity and Emergency Aid Reserve SIA sustainability impact assessment SME small and medium-sized enterprise SPS sanitary and phytosanitary standards SRHR Sexual and Reproductive Health and Rights TAIEX Technical Assistance and Information Exchange TEC-MED Development of a Transcultural social-ethical- care model for dependent population in the Mediterranean basin TEI Team Europe initiative TRIPS Trade-Related Aspects of Intellectual Property Rights TSD trade and sustainable development UHC universal health coverage UNDP United Nations Development Programme UNHCR United Nations High Commissioner for Refugees UNICEF United Nations Children’s Fund UNOPS United Nations Office for Project Services UNRWA United Nations Relief and Works Agency for Palestine Refugees in the Near East WFP World Food Programme 4 Policy brief 5European support for improving global health systems and policies List of tables, figures and boxes Tables Table 1: Examples of relevant initiatives funded by Global Europe and its predecessor programmes (EDF, EFSD) 30 Table 2: Examples of EU research and training partnership main instruments 40 Table 3: Examples of initiatives supported by Horizon Europe 2021–2027 41 Figures Figure 1: Mapping EU global health actions through the lens of policy tools and areas 17 Figure 2: 2013–2020 EU commitments to UN bodies 35 Boxes Box 1: Redesigning global health governance (a perspective by Ilona Kickbusch) 10 Box 2: The European Health Union: Internal action with cross-border implications 12 Box 3: Global health goals moving forward (a perspective by Ilona Kickbusch) 14 Box 4: Main policy areas analysed 16 Box 5: Moving from Health in All Policies to Health for All Policies 19 Box 6: Transversal topics. One Health: Technical standards on food and AMR 22 Box 7: Stakeholders remain divided on the question of balancing intellectual property rights and access to medicines 23 Box 8: The EU–Africa Global Gateway Investment Package includes health system strengthening among its areas of focus 24 Box 9: Transversal topics. The digital transformation: Implementing digital solutions and reducing inequities 26 Box 10: EU accession candidates and neighbourhood receive financial and technical support towards adopting EU standards in the area of health 28 Box 11: Global Europe’s 2021–2027 thematic multiannual indicative programme aims to address global challenges and is especially relevant to advancing health and global health priorities 29 Box 12: Transversal topics. Numerous EU programmes reflect its commitment to promoting human rights and human development 31 Box 13: EU Humanitarian Air Bridge as a prime example of humanitarian aid during COVID-19 and the conflict in Ukraine 32 Box 14: ACT-A AND COVAX bring together stakeholders in the fight against COVID-19 33 Box 15: Declaring commitment to ending COVID-19 and improving preparedness for future pandemics at the Global Health Summit 2021 35 Box 16: The Quadripartite Memorandum of Understanding (MoU): Avenues for collaboration on One Health 36 Box 17: Country examples of the EU’s collaboration with the World Food Programme 38 Box 18: Transversal topics. The European Green Deal has ambitious climate goals over the coming years 39 Box 19: Transversal topics. EU action against a global health workforce crisis 42 6Policy brief Key messages • The EU has huge impact – and huge potential impact – on global health. It is one of the world’s largest markets, aid donors, health care innovators and trading powers. It influences global health and health policy directly and indirectly, through its explicit global health policies and through the effect of its other policies on global health. • There is growing recognition that a more coherent EU approach to global health could strengthen its governance and improve global health policies, due in part to the momentum created by COVID-19. • The 2022 EU Global Health Strategy and 2024 Council conclusions EU global health strategy – better health in a changing world set out principles for the future that reflect EU values and a commitment to: better health and well-being across the life course; stronger health systems; and action to prevent and combat health threats. • There is scope for more purposeful efforts to create synergies between EU policy instruments and global health. This means aligning policies that were deliberately designed to address global health and those with unintended (spillover) impacts. It also means coordinating diverse Commission directorates and agencies and other EU actors such as the External Action Service and European Investment Bank. • There are five ‘obvious’ EU policy areas where instruments could be aligned with global health goals: trade in goods and services; public investment and fiscal instruments; official development assistance and humanitarian aid; solidarity, voice and multilateralism; and research and training. There are other important areas that could also be aligned, such as climate change policy. • Repurposing existing policy instruments in areas such as those to advance global health is not straightforward because: • the instruments were typically developed to meet specific (non-health) needs and are ‘owned’ by teams who are not primarily focused on global health • adjusting instruments to encompass global health objectives can imply some pooling of sovereignty, which Member States may be reluctant to endorse • EU policy action on global health takes place in a crowded arena with multilateral organizations, non-governmental actors, and private and philanthropic institutions, and can unintentionally cut across other initiatives. • Collective and careful work with EU policy communities can help integrate new, global health- focused, approaches into ‘non-health’ areas despite their established legal and political frameworks. • Building consensus around a vision of global health with national governments across the EU can address concerns about sovereignty and foster commitment. • EU coordination across agencies and engagement with multilateral forums can help harmonize global health approaches and reduce duplication and fragmentation. • EU global health tools need to be ‘managed’ in context and this means being clear about: • which of the four types of instrument they involve: policy; funding; information; or technical support • the geographical context in which the instrument will be used and whether or not this categorization is relevant to the coherence of the global health policies. 7European support for improving global health systems and policies Executive summary The European Union (EU) is one of the world’s largest markets, aid donors, health care innovators and trading powers. As such, many of its policies affect global health. EU policies affect global health directly, as with overseas aid, trade policy or support for the World Health Organization (WHO). They also affect global health indirectly, as with the many internally focused policies which affect health and health policy options in other countries, such as research priorities or medicines regulation. The extensive range of policy areas that touch global health mean that the EU has a wide range of policy tools which inevitably shape global health, and which the EU can use intentionally to shape health governance and outcomes worldwide. The broad shape of any coherent strategy or approach to global health, in the complex institutional environment of Europe, must align priorities with tools, identifying what the EU wants to achieve in the global health sphere and which policy tools will be best suited to have the desired effects. Alignment requires consideration of the different ways in which countries near the EU already relate to it (e.g. accession candidates) and should include an appreciation of which actors should use the different policy tools, with respect to subsidiarity as well as the advantages of joint action in some areas. In Part I, we present a method for identifying relevant policy tools in EU global health policy in a select set of areas which have clear and important effects on global health: trade in goods and services; public investment and fiscal instruments; official development assistance (ODA) and humanitarian aid; solidarity, voice and multilateralism (the EU’s role in the broader global health governance system); and research and training. The method involves identifying and delineating a policy area and then focusing on the identification of EU instruments with global effects that can be considered as part of an approach to global health. It could also be useful in policy areas that we do not discuss in depth here, such as climate change policy or agricultural and food safety policy. This Brief is intended to advance, rather than conclude, the debate and should not be read as claiming that any given policy area should be excluded from the EU’s global health thinking. In Part II we present the range of key policy tools in each area, which reflect the different organization, governance and challenges of the different policy areas – ranging from EU decisions on tariffs and regulation in trade through to the EU approach to various multilateral bodies such as the G7, G20 and United Nations (UN). The review of EU instruments clearly shows the immense scale of the impact of existing EU policies on global health, and the potential that a coherent approach could have to strengthen global health governance and improve global health policies and outcomes. The EU affects global health through many different policies; the question is how, when and by whom these policies will be used for global health. 8Policy brief 1. Introduction The EU’s foundational treaties and political history barely spoke of health, let alone global health. They focused on markets, integration, regulation and industrial policy. The situation is very different now, for the EU and the world recognize that EU policies span across a range of areas that are relevant to health. The EU has policies with direct and clear relevance to global health, such as ODA, trade policy and, most recently, the EU’s Global Health Strategy. The EU’s influence on global health comes from the power of its various policy tools, wielded by one of the largest and most connected economic and political units in the world. Now, the sources of that influence are recognized as EU policy tools that can be used. The questions are: 1. Which policy tools will be used? Existing policies were not developed by accident and the people who support them might not appreciate having their work redirected into a global health agenda. Integrating new strategic approaches into areas with entrenched legal and political frameworks can be challenging. 2. In pursuit of what priorities? Global health can be a goal in its own right, but even accepting that raises questions about just what vision of global health the EU should pursue. Global health is always inextricably bound up with other goals, such as economic development abroad, geopolitical alliances and tensions, the maintenance of a rules-based international order, and the promotion of the European economy. 3. And, by whom? Framing existing EU policies in light of global health priorities opens up a variety of questions. The global health arena hosts a range of different players, from national governments to multilateral organizations, non-governmental actors, private and philanthropic institutions. The myriad of interactions, projects and initiatives generated by the interplay of different global health actors can be challenging to appreciate and navigate. In this context, building synergies between Member State and EU action in areas such as development assistance and multilateral forums can contribute towards reducing duplication and fragmentation of actions and ensure converging goals may be pursued at both the EU and national levels. In global health, as in health policy within its borders, the EU exerts a major influence on health policy. In the same way that an EU role in health, European health goals and EU health policy have become undeniably relevant for the EU’s internal politics (as underscored by the COVID-19 pandemic), the EU’s role in global health is increasingly evident in a context of cross-border health threats and the effects of globalization and interconnectedness on human health, animal health and the environment. There is still some debate about the scope and contours of the EU’s role in global health, but by now the importance of its role is recognized. What is still being debated is what policy instruments the EU should wield in pursuit of its global health actions and what its new Global Health Strategy should achieve in the coming years. Part I: Understanding EU Global Health Policies Policy brief 9European support for improving global health systems and policies 2. Evolution of EU global health strategies The 2010 Communication on the EU Role in Global Health focused on highlighting shared views on health topics that could unite Member States and the EU. The development of EU global health strategies involves the twin processes of recognizing how EU policies affect health, and then developing and implementing a vision and priorities for using those policy tools, including by determining where health fits in broader EU strategic conversations and goals. While the EU had taken steps towards developing a shared voice and vision, such as the 2005 European Consensus on Development and recognition of the EU’s global health role in the 2007 Health Strategy, the first joint EU policy statements on global health took shape in the 2010 Council Conclusions paired with a Commission Communication enunciating the priorities and actions for implementation, including emphasis of EU goals and values, such as universal health access and human rights, as well as proposed steps towards strengthening coherence, such as through coordinating views in multilateral organizations and overseas aid (EUR-Lex, 2005; European Commission, 2007, 2010; Council of the European Union, 2010). COVID-19 gave a new momentum to develop a stronger and more coherent global health strategy. While consensus on the usefulness of a new EU global health policy might reflect the achievements of the 2010 efforts and the many things that have changed since then, the COVID-19 pandemic has been a catalyst for reconsideration of the topic. Against the background of major advances in EU health policy overall (Greer & Jarman, 2021; Greer et al., 2022a; Brooks et al., 2023), Commissioners Stella Kyriakides (DG SANTE) and Jutta Urpilainen called for the development of a new EU Global Health Strategy, they explicitly referenced the harm caused by the COVID-19 pandemic, the extent to which the years since 2020 had seen success in meeting sustainable development goals (SDGs) go into reverse, and the health security issues evoked by their statement that “viruses know no borders”. They went on to specify the goals of an EU strategy: “That is what our citizens and partners expect: robust action to secure their health – action rooted in the universal values of human rights, equity, solidarity and cooperation. “We will act on the basis of a new and impactful Global Health Strategy as part of the Global Gateway: we must improve health systems so that they can more effectively prevent and respond to global health threats as well as tackle all infectious and non-communicable diseases. We must address inequalities and advance towards universal health coverage. We must have strong strategic health partnerships with other regions in the world. We must reinforce local health manufacturing capacities, in Africa and beyond. And we must put the One Health approach at the core of our action, recognizing the intrinsic connection between the health of people, animals, plants and their shared environment.” (European Commission, 2022a, undated, a) The new Global Health Strategy was launched in November 2022. The European Commission released its much-anticipated Global Health Strategy in November 2022 (European Commission, 2022b). This was the first strategic document released since the 2010 Commission Communication and Council Conclusions (2010) and the first EU Global Health Strategy. As an external dimension of the European Health Union (EHU), the Strategy continues the EHU’s mission to sustain health systems that function in a way that reflects the EU’s core political values including solidarity while also preventing potential future health disasters (European Commission, 2022b). The 2022 EU Global Health Strategy lays out 20 Guiding Principles that aim to steer future global health initiatives (summarized in the Annex of this Policy Brief). Overall, future health initiatives are meant to encompass the core EU values considering health for all, including humans and ecosystems, that reflect the intertwined nature that is further being discussed in the EU space in 2023.The Strategy’s three overarching priorities are: 1. Delivering better health and well-being of people across the life course. 2. Strengthening health systems and advancing universal health coverage. 3. Preventing and combatting health threats, including pandemics, applying a One Health approach (European Commission, 2022b). These principles mean enhancing the capacity and resilience of health systems through increasing workforce capacity and capability, keeping abreast of technology, and the integration of health policies across sectors. They also influence each other. For instance, the first principle focuses on tackling root causes of ill-health, specifically for women, girls and populations previously overlooked. This directly hits upon the first and second priorities. The Strategy presents policy tools to achieve its goals. Global mechanisms of financing are repeatedly mentioned, as are pandemic preparedness mechanisms. Moving forward, global health actions will take the One Health approach, considering the role of health across sectors. The aim of this brief is to explore these relevant policy mechanisms and tools in light of the new Global Health Strategy, its priorities and guiding principles. 10 Policy brief Box 1: Redesigning global health governance (a perspective by Ilona Kickbusch) The COVID-19 pandemic has led to a wide range of policy recommendations on new governance and financing structures for global health, many of which are part of the EU Global Health Strategy. The Strategy calls for a “new global health order” and makes a range of proposals for redesign. In the global arena, the focus of the many reform proposals lies with: equity of access; financing of pandemic prevention, preparedness and response (PPR); transparency; solidarity between countries; cooperation between agencies; high-level political decision making; and inclusive governance. There has been strong criticism of vaccine inequity and that countries of the global south, as well as the voices of civil society, were not sufficiently included in the governance of the COVID-19 response. Five developments that will significantly shape global health governance deserve special mention: 1. The Member States of the WHO decided to embark on negotiations for a global pandemic accord to be finalized in May 2024. This was first proposed by Charles Michel, the President of the EU Council in 2020. Supportive of these negotiations is the work on adapting the International Health Regulations (IHR) based on the experiences of recent and ongoing outbreaks and pandemics. Both together will strengthen the role of the WHO in pandemic preparedness and response. 2. Many of the initiatives to evaluate the COVID-19 response of the WHO, other organizations and countries underlined the need to also strengthen the WHO financially. A historic step was reached in May 2022 when Member States agreed to increase the assessed contributions to the organization by 50% by 2030. The EU strongly supported this move. The next step will be the strong political and financial support to the investment round for WHO in 2024. 3. During COVID-19, a set of new governance mechanisms were created, including the Access to COVID-19 Tools Accelerator (ACT-A), a ground-breaking global collaboration to accelerate development, production and equitable access to COVID-19 tests, treatments and vaccines. The EU contributed significantly to these new mechanisms. The COVAX pillar of the ACT-A was set up to accelerate the development and manufacture of COVID-19 vaccines and to guarantee fair and equitable access for every country in the world. This goal was not achieved – ACT-A and COVAX are being reviewed to ensure more equitable distribution mechanisms and governance in times of crisis. One proposal being negotiated is a medical countermeasures platform. 4. A new finance mechanism was officially established in September 2022 through G20 negotiations between health and finance ministers. The Pandemic Fund finances critical investments to strengthen pandemic PPR capacities at national, regional and global levels, with a focus on low- and middle-income countries (LMICs). It is managed by the World Bank with technical support from the WHO. It aims to provide a dedicated stream of additional, long-term financing to strengthen PPR capabilities in LMICs and to address critical gaps through investments and technical support at the national, regional and global levels. It has initial funding of USD 1.3 billion and the goal is USD 10 billion. The EU is the largest contributor. 5. The calls for reform of the intellectual property (IP) regime at the World Trade Organization (WTO) – the Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS) – are now even stronger based on the major disagreements between WTO members on IP in relation to vaccines, therapeutics and diagnostics. The EU takes a strong stand to protect IP and – together with the USA and Switzerland – is heavily criticised by representatives of LMICs and civil society, as well as during the negotiations for the pandemic accord. Contentious issues also include benefit sharing and technology transfer. Council Conclusions The 2022 Commission Global Health Strategy was followed in January by Council Conclusions on “EU Global Health Strategy: Better health for All in a changing world.” This follows a common pattern in which the Commission’s view are endorsed in somewhat amended form, by the Council. Council conclusions agreeing with a Commission are a powerful support for implementation of a strategy because they show that the member states are also committed to the agenda. Council conclusions are also worth reading in detail because they are formulated in careful diplomatic negotiations, so nuances of language and inclusion or exclusion of topics are important. The January 2024 External Relations (RELEX) Council meeting endorsed the Commission’s Global Health Strategy and a shared commitment of the EU and its member states to a “leading role” in global health. It reaffirmed the Council’s commitment to the principles of “solidarity, humanity, equity, gender equality, and respect for human rights.” It further asserted that “The Council remains committed to policy coherence and a human-rights based approach and further acknowledges that EU contributions to global health go beyond the health sector, including in areas such as peace and security, agriculture, climate and environment, education, research and innovation, nutrition and food security, social protection, trade and water, sanitation and hygiene.” It endorses the three priorities of the Commission strategy: “Deliver better health and well-being of people across the life-course; strengthen health systems and advance universal coverage (“equitable access to quality, accessible, acceptable and available health services including sexual and reproductive health care services”); prevent and combat health threats, including pandemics, applying a One Health approach.” The conclusions characterise the strategy as a “new paradigm that engages all relevant areas of external policy, with an important link to internal policies”. It calls on the Commission, High Representative and member states to “apply the guiding principles and implement” by means including “concrete action to promote global health across relevant sectors...; strengthening capacity and enhancing coordination, including through informal cooperation, to boost the efficiency and impact of initiatives and actions, ensure that the EU and its member states are speaking with one voice in relevant international fora and intensifying dialogue and joint communication efforts at multilateral, regional and national level; taking a proactive and constructive role to strengthen multilateral cooperation by filling existing gaps in global governance and ensuring complementarity and coherence of action, 11 European support for improving global health systems and policies and with a strengthened and more effective, accountable, and sustainably financed WHO at its core, noting that the EU seeking formal observer status at WHO could be addressed and decided upon in the relevant Council structures; expanding bilateral, regional, trans-regional and global partnerships...; regularly taking stock of progress and impact.” It finally commits to a broad range of partnerships inside and outside the EU and invites the Commission and EEAS to “develop a coherent EU global health diplomacy... augment global health capacity in key EU delegations... monitor and evaluate the implementation and impact of the Strategy.” 12 Policy brief 3. Competencies and structure With the Member States reticent about pooling sovereignty, EU external action on health is based on voluntary coordination that draws on existing structures and tools. Historically, EU external action has not developed in the same way as the largely internal policy areas. From its inception, the EU had some strong competencies vis-à-vis the outside world. These grew out of its early missions as a Coal and Steel Community, and later a common market, and were focused on relevant trade policy issues. Over time, as the EU added competencies, specific Treaty clauses authorized action in fields such as international development aid and cooperation. Member States, nonetheless, were reluctant to create a EU foreign policy as such, and the history of EU action in external affairs took a different route, with a prominent role for voluntary coordination (Petiteville, 2003). Those familiar with EU health policy will recognize this pattern, in which EU policies made without regard to health affect health, and over time elicit efforts to refocus them on health and increase their coherence as health policies (Greer et al., 2022b). It can be seen in global as well as internal EU health policy. Member States’ interest in retaining their freedom of action in international affairs has traditionally given EU foreign affairs an intergovernmental cast, with the Commission active within the realm of its competencies (e.g. trade) and a separate approach for foreign policy coordination, primarily via the European Union External Action Service (EEAS). Many of the European Commission’s directorates contribute to global health as an extension of their internal roles. EU external affairs are primarily handled by the High Representative of the Union for Foreign Affairs and Security Policy (‘High Representative’) and the EEAS, the EU’s small diplomatic corps, which answers to the High Representative and is not part of the Commission (although supported by a Service Department for Foreign Policy Instruments (FPI) within the Commission). The Commission, nevertheless, has many of the key competencies as well as expertise and resources in the key areas of EU action, including health and coordinating between the EEAS, Commission, High Representative and member states is a major challenge and focus of EU external affairs. The Directorates General (DGs) that are involved in global health policy are a mixture of those largely specializing in external affairs and those that contribute to global health as an extension of their internal roles. The list of DGs with a strong external face and relevance for global health due to their internal activities starts with DG SANTE (health), but includes many other DGs due to the strong external effects of many EU internal policies, such as DG GROW (Internal Market, Industry, Entrepreneurship and SMEs), DG JUST (Justice and Consumers), DG AGRI (Agriculture and Rural Development, responsible for the Common Agricultural Policy), DG CLIMA (Climate Action), DG ENV (Environment) and the new Health Emergency Preparedness and Response Authority (HERA), which is currently organized as a Commission Service whose work is closely interlinked with that of DG SANTE within the Commission. The European Health Data Space is formally part of DG SANTE and, once operational, will be internally focused. However, EU data legislation is globally influential and likely to serve as a model for doing business in the global market. The 2022 Global Health Strategy further highlights the role of the EU Commission’s plan in extending the current internal roles outwards, connecting DGs cross-sectorally in pursuit of global health goals. Ultimately, the EU is so important in the world that, like other major economies, its domestic decisions all have global health implications, and a Strategy could recognize almost any of its competencies’ relevance to global health. Box 2: The European Health Union: Internal action with cross‑border implications The EHU acts as the EU’s internal force for health. Legislative changes proposed and being implemented as part of the Commission communication on Building a European Health Union (EUR-Lex, 2020a) include: • strengthening the mandate of the European Centre for Disease Prevention and Control (ECDC), the EU agency tasked with preventing and surveilling health threats and infectious diseases across the EU • strengthening the mandate of the European Medicines Agency (EMA), the EU agency that ensures pharmaceuticals that enter the market in the EU adhere to rigorous standards and regulations • establishing a new Health Emergency Preparedness and Response Authority (HERA); this Commission service was created in the wake of COVID-19, to strengthen the EU’s preparedness and response capacity, including with regards to medical stockpiling and horizon scanning. In conjunction with the new Global Health Strategy, HERA released a State of Health Preparedness Report setting out key areas for action to reinforce the EU’s preparedness capacities in light of future health threats (European Commission, 2022c) • upgrading Decision 1082/2013/EU into a Regulation on serious cross-border health threats. Thus, the EHU has reshaped the ways in which the EU tackles health, recognizing that borders do not stop disease. In recognizing the cross-border nature of disease, the EU sets up an internal framework more ready to respond to potential diseases. This internal action may also improve global health, as a pandemic- prepared EU (through bodies like the ECDC and HERA) will be more likely to prevent disease from transmitting across borders into regions globally. Moreover, the Strategy foresees strengthening the cooperation of agencies such as the ECDC and EMA with their African counterparts, the African Centres for Disease Control and Prevention (CDC) and African Medicines Agency, which is currently being established (European Commission, 2022b). Beyond strengthening the EU’s preparedness and response framework, EU internal health policy also extends to actions addressing health and universal health coverage (UHC) issues within the EU’s borders, such as the Europe’s Beating Cancer Plan and Pharmaceutical Strategy. 13 European support for improving global health systems and policies DGs that focus on external affairs and are especially relevant to global health include: DG INTPA (Institutional Partnerships), DG ECHO (Civil Protection and Humanitarian Aid Operations), DG NEAR (Neighbourhood and Enlargement), DG AGRI (Agriculture) and DG TRADE (Trade). DG NEAR is the leading DG for accession candidate states and those that are part of the Neighbourhood Policy area. DG INTPA’s remit is responsible for the EU’s international partnership and development policy, including the European Consensus on Development. DG ECHO’s remit is primarily international and its origins were in that area, but its role in Civil Protection (e.g. the RescEU programme) has given it a profile internally in recent years (for further information on EU instruments in these policy areas refer to the section on ‘Official development assistance and humanitarian aid’). DG TRADE implements the powerful, exclusive or mixed, EU competencies in international trade (see the section on ‘Trade in services and goods’). Agencies such as the ECDC, EMA and EFSA play a major role in formulating international standards that may have global influence. Most EU agencies have limited remits in technical areas as well as limited executive authority. This can paradoxically contribute to their ability to produce evidence, guidelines and standards that are well regarded and influential worldwide: because it is clear that they are more technical and less political, governments and experts can trust them. Trust must be earned, but it is easier for agencies to earn it if they have clear objectives and technical focuses. In health, the ECDC and the EMA gained worldwide visibility for their role in the COVID-19 pandemic. At the same time, agencies like the European Food Safety Authority (EFSA) work to promote food safety as well as to prevent zoonotic health threats and those that might spread through food contamination (Bronzwaer et al., 2021). The EU role in formulating shared international standards, often in technical but important areas, is hard to overestimate, and agencies are often a key part of that global influence. EU actors, such as the EIB and the European Court of Justice, have powerful effects on global health action. The High Representative and the Commission, along with the heads of government in the European Council, are at the centre of most conversation about EU global policy, and of this brief. It is nonetheless worth noting that the EU has a number of actors with powerful external effects. Some of these are indirect, as with the European Court of Justice (ECJ)’s exchanges with other high courts, which diffuse European legal concepts and doctrines. Others are quite direct, as with the financial and monetary policy operations of the European Central Bank (ECB), which often coordinates with other central banks, or the loaning of various European and other European multilateral banks, which can affect the resources and policy orientations of debtor countries. While some of these organizations, such as the European Investment Bank (EIB) and the European Bank for Reconstruction and Development (EBRD), are very low profile, their actions are part of the EU’s effect on global health. In recent years, the role of such banks has become increasingly important, along with philanthropic actors and private sector funding, for development and international cooperation funding mechanisms. While they are often independent – the ECB in particular enjoys a treaty base that deliberately limits its accountability to member states or the public – there is a measure of pragmatic information exchange and perhaps coordination. Coordinating with these actors is also part of the High Representative’s responsibilities as well as being part of the EU’s overall coordinating machinery headquartered in the Council and Commission secretariats. More information on the EU’s political and financial cycles, as well as the structures, legislative provisions and instruments of relevance to its health and global health policies can be found in the European Observatory’s book ‘Everything you always wanted to know about European Union health policies but were afraid to ask’ (Greer et al., 2022b) and the policy brief ‘European support for improving health and care systems’ (Fahy, Mauer & Panteli, 2021). 14 Policy brief 4. Prioritization Setting the ‘right’ EU global health priorities depends on matching intended goals with real or realistic policy options. Determining which policy tools are to be part of a strategic EU approach is a process based on first understanding the priorities and goals of the strategy. For some purposes, the right tools might be in trade policy, for others, ODA, while in other cases the right tools might be a blend from across different policy areas. The EU Global Health Strategy of 2022 covers the work of DG SANTE and DG INTPA, but European policy tools that affect and can be used to shape global health stretch far beyond their activities. Understanding EU global health and prioritizing actions requires triangulating between the tools (what the EU can do) and the goals (what are the intentions of EU action above and beyond what is already being done?). The Global Health Strategy will contribute to shaping Europe’s place in the world, but only if it matches goals with real or realistic policy tools. Determining the goals that the EU is to pursue in health is a political process that must balance a variety of interests. The EU and its Member States face many problems to which global health action is relevant, and different actors place varying weights on them. Determining the goals that the EU is to pursue in health is a political process that must balance a variety of interests. Interests to be found in any international strategy can include the ambition to tackle emerging challenges such as pandemics and to implement effective One Health approaches to curb future health threats. Others may be related to navigating various geopolitical climates, to building support for a particular international order (such as one with a strong role for international law and human rights), advancing health and human development as a goal in its own right, or promoting internal economic growth or economic development abroad. These different goals tend to map onto both particular policy tools (for example, trade policy is historically driven by domestic economic concerns) and policy constituencies. An EU Global Health Strategy, just as any other EU strategy, demarcates a set of linked policy tools and sets out the priorities that should affect their use. Although reconciling different interests and priorities is a challenging process, the Global Health Strategy identifies the scope of global health goals, alludes to some of the relevant tools, and guides their use in shaping global health policy. Box 3: Global health goals moving forward (a perspective by Ilona Kickbusch) No country is safe unless all are safe. Achieving global health equity is the key goal of the multilateral system for health as expressed in goal 3 of the SDGs. Good health is essential to sustainable development. Global health is both about health challenges that transcend national borders and addressing North–South divides. It focuses on the needs at the country level as well as the importance of uniting countries around a comprehensive and coordinated strategy, such as UHC. Health outcomes in developing countries continue to be undermined by a triple burden of historical infectious diseases, new emerging infectious diseases and an epidemic of non-communicable diseases, such as diabetes and heart disease. Compounded with fragmented health systems and lack of resources, this presents a huge challenge to global health equity. Global health rests on three pillars: governance, instruments and diplomacy. The growing interconnectedness between these three pillars is an essential driving force of global health in the 21st century. In view of the increasing geopolitical divide, the combination of all three is essential – for example, to reach agreement on a new pandemic accord. The WHO as a normative organization lies at the centre of the governance of global health. But, the field of global health has become more diverse and contested. In the past 20 years, a number of new health organizations have been created, and successful global health action is increasingly dependent on the cooperation between this wide and diverse network of actors. Present financing models have led to a competitive marketplace for funding global health – mainly through ODA and replenishment processes – while global common goods funding is neglected as the pandemic has shown. Global health is dependent on a Health in All Policy (HiAP) approach that addresses social, environmental and commercial determinants of health. The decisions in other policy arenas and organizations – on climate, food, migration, economic development – impact significantly on the health of populations. The need to expand global health to include One Health models and planetary health is becoming clear. Global health is always at the interface of national and security interests, and the protection of economic interests and industries (for example, tobacco and pharmaceuticals, but increasingly digital technologies and AI), including patents and IP rights. Almost all countries use health negotiations to promote their trade, industrial as well as technology policies or their perceived economic interests as well as their ideological positions, for example in relation to sexual and reproductive health and rights. In recent years, global health has been criticised for being based on perspectives and interests of the Global North. The voices to ‘decolonize’ global health have grown significantly and have been supported recently by the G20 presidencies of Indonesia and India and determined action by the African Centres for Disease Control to strengthen Africa’s voice in global health. The lack of sustainable funding of much of global health –including significant support to establish primary health care – is also severely criticised. In moving forward, global health will need a new planetary mind frame, more equitable and inclusive governance, and sufficient and sustainable funding. 15 European support for improving global health systems and policies There is a broad range of EU instruments that can be used to impact health globally. There are many tools the EU uses that affect health and can be part of a successful and powerful global health strategy. To capture this complex set of policies, we categorized EU tools relevant to global health. The categories were kept sufficiently abstract and mutually exclusive to allow assigning the instruments for EU action for global health. The categories were designed in support of the discussion of the EU Global Health Strategy. The intention is to produce a clear picture of what is already done by the EU on global health as well as where the new Global Health Strategy may guide the EU’s actions in future. This lends itself to discussing policy consistency and synergies between different instruments. The categories were therefore designed irrespective of the EU policies stipulated in the Treaty and also irrespective of the remit of the different Directorates General. The main results are presented in Part II of this brief. Ownership of the instruments can be looked up in the detailed tables in the annex. EU instruments were systematically researched and mapped through: 1) literature search; 2) analysis of the websites of different DGs; and 3) expert advice and consultation. The research team was composed to reflect technical competence matching the main categories. We are also grateful to our external reviewers for helping us to close gaps and identify inaccuracies. EU global health tools can be grouped into four types: policy, funding, information and technical support. We divided tools used by the EU in global health into four main areas based on the principal content and form of the support provided. The four categories are policy, funding, information and technical assistance. These categories had been previously developed and used by Fahy et al. to classify instruments relevant to the EU’s internal health action and policies in the policy brief on ‘European support for improving health and care systems’, although with slightly different meanings and implications (Fahy, Mauer & Panteli, 2021). For the purpose of this brief, policy refers to wide-reaching EU actions, such as tariff decisions, that influence global health by shaping what the EU does internally or supports in international forums. Policy decisions might not directly involve big sums of money but can have dramatic effects. For example, the EU single voice in multilateral organizations can shape what they do, and trade preferences can have enormous consequences for exporters to the EU. Funding refers to direct EU expenditure and financial support. The EU is one of the larger players in ODA and global health, and even to simply note its large ODA expenditure is to understate its external financial impact. EU instruments based primarily on funding involve EU financial support of particular partners in pursuit of particular goals. Information is an often underestimated tool of influence and one in which the EU is strikingly strong among major global actors. It involves providing and circulating information, guidelines and technical knowledge, often coupled with the development of networks of experts, provision of advice and training. Countries with limited resources and close relationships with the EU, in particular, will often appreciate and be influenced by such engagement. Technical assistance, finally, refers to targeted support such as that provided by the civil protection mechanism (which includes a mechanism, the European Medical Corps, for sending emergency medical staff to the sites of disasters) as well as assistance on issues such as accession (for pre- accession states) or trade capacity building. Global health tools can also be grouped by policy area: trade in goods and services; public investment and fiscal instruments; ODA and humanitarian aid; solidarity, voice and multilateralism; research and training partnerships. Defining the boundaries of global public health might seem to be a largely academic enterprise, but it is one with political stakes. If global public health includes policies on preventing AMR, then food and agricultural policy internal and external to the EU become part of global health policy. If the health workforce is part of global health policy, then education, training and free movement become part of global health policy. In delineating the EU’s Global Health Strategy, therefore, it is helpful to think in terms of policy areas and evaluate the extent to which they can contribute to any particular goal. The policy areas we defined include public investment and fiscal interests, in which the EU supports mobilization of investment. This can involve: both public and private investment, which is assembled by risk-sharing mechanisms or other forms of incentive; ODA and humanitarian aid, which refers to direct assistance to governments and non-governmental organizations (NGOs) for response to major shocks as well as development in third countries, including the direct neighbourhood and accession candidate countries; solidarity, voice and multilateralism, which refers to the EU’s participation in and role in shaping the global health governance environment, which involves both coordination in decision making and financial support; and finally, research and training partnerships, which shape and support global networks of health research and workforce (see Box 4 for a short summary of the policy areas). Sections in Part II discuss the primary instruments identified in each of these policy areas and classified according to type, as well as potential strategies for maximizing the EU’s role in global health. These policy categories are not exhaustive, but serve to cover a vast proportion of the EU instruments relevant to global health, as well as to demonstrate the added value in mapping available tools and what they do to support the implementation of the Global Health Strategy priorities. 16 Policy brief Box 4: Main policy areas analysed The main policy areas analysed in this brief are: • Trade in goods and services: Instruments included in this policy area pertain to the area of trade, reflecting how trade affects different types of product (e.g. potentially hazardous commercial goods such as cigarettes, medicines, or medical devices), intellectual property, and services (e.g. cross-border health care and mobility of the health workforce). • Public investment and fiscal instruments: The EU has adopted a new global investment strategy, the Global Gateway, which will leverage different types of instrument to boost growth and attract investment for infrastructure, digitalization and the modernization of health systems. Some of the instruments included in this area take a global approach, while others, which are primarily dedicated to internal actions, have important spillover effects on third countries. • ODA and humanitarian aid: This section captures the commitment to ODA and humanitarian aid of the EU and its Member States. There are several tools by which assistance is provided to third countries, which reflect the geographical idiosyncrasies of the different beneficiary countries. Support for human development, rights and health systems strengthening is at the centre of EU development and humanitarian action. • Solidarity, voice and multilateralism: The EU is an advocate for multilateral cooperation and cooperates with a wide range of actors in the global health arena to strengthen health systems in beneficiary countries, while also empowering them and forging partnerships. This policy area captures the most important multilateral cooperations and partnerships, and explores how the EU shapes its position and voice within these forums. • Research and training partnerships: Research and training partnerships encapsulates the policy area through which EU instruments support scientific excellence and training beyond the EU’s borders. 17 European support for improving global health systems and policies Figure 1: Mapping EU global health actions through the lens of policy tools and areas Trade in goods and services Public investment and fiscal ODA and humanitarian aid Solidarity, voice and multilateralism Research and training partnerships Policy Commission communication on the EU role in Global Health Science for diplomacy Joint Communication on strengthening the EU’s contribution to rules- based multilateralism AU-EU Partnership Sanitary and phytosanitary standards (SPS) Global Gateway European Consensus on Development Team Europe and Team Europe Initiatives Trade agreements Team Europe European Neighbourhood Policy and Enlargement Negotiations Trade arrangements European Consensus on Humanitarian aid Consultation mechanism Civil Protection Mechanism Trade defence Policy reviews Funding Aid for Trade Global Europe Funding for humanitarian aid Transversal (shown in other columns) Horizon Europe Instrument for Pre- accession Assistance (IPA III) Global Europe Vocational training (VET) Interreg Solidarity and Emergency Aid Reserve (SEAR) InvestEU EIB Global Instrument for Pre- accession Assistance (IPA III) EU4Health Manufacturing pharmaceuticals agreement with Africa (Global Gateway) Connecting Europe Facility Manufacturing pharmaceuticals agreement with Latin America and the Caribbean (Global Gateway) European and Developing Countries Clinical Trials Partnership (EDCTP) Technical assistance European Civil Protection Pool Opportunity Driven Vocational Training (Team Europe Initiative) Technical Assistance and Information exchange instrument (TAIEX) Marie Sklodowska-Curie Actions TWINNING MediPIET Information Analysis and assessment Knowledge4Policy 18 Policy brief 5. Places Policy problems differ depending on the geographical area, but geographical categorization does not necessarily support coherence. Places are crucial in global health. Issues, stakes, priorities and problems all differ from country to country. The EU has a dense conceptual and legal framework for, in particular, countries in the region around it. This framework of accession candidates, European Economic Area (EEA) members, neighbourhood states and other categories has a history that separates them from ‘global health’ issues. It is not, however, at all clear that this framework accurately reflects EU problems, priorities or tools, or how separating out these different categories creates policy coherence or enables prioritization. In addition, the EU engages multilaterally with many other actors beyond the national level. In this regard, the WHO and the UN, with their headquarters in Geneva and New York respectively, represent focal points for collaboration and coordination of global health initiatives (Hosli, 2022). The region around Europe is a place in which health and other policies affect Europe, and European policies can have particularly dramatic health effects. The area around Europe contains a very diverse set of countries which have varying health statuses, political relations with the EU, and health or economic impact on the EU. Perhaps reflecting these challenges, the EU subdivides the countries around it fairly precisely. These countries exist in a somewhat ambivalent relationship to EU ‘global’ strategies, partly because of the depth and complexity of exchanges and partly because of the institutional organization of the EU. Nonetheless, the region around Europe is both a place in which health and other policies affect Europe, and where European policies can have particularly dramatic health effects. The EU’s 27 Member States, for example, make up half of the 53 Member States of the WHO European Region. A coordinated EU voice in the Regional Committee can make the EU extremely influential in that body. The EEA is at bottom a system for connecting the EU with a set of three countries: Iceland, Liechtenstein and Norway. These are not EU Members but are very tightly integrated into the EU. Along with Switzerland, they are Members of the European Free Trade Association (EFTA). EFTA maintains its own institutions, including a court. Switzerland, which is important in global health for a number of public and commercial reasons, belongs to EFTA but not the EEA, preferring to manage relations with the EU outside the EFTA–EU relationship through bilateral agreements with the EU. The rest of this section discusses the countries around the EU in the terminology of the EU. In most cases, the problems with these older clusters of countries are apparent; accession countries, for example, include countries as different as Türkiye and Ukraine, the United Kingdom is in an unstable category of its own (Greer & Laible, 2020; Fahy et al., 2022), and almost nothing – and certainly not relations with the EU – unites the designated neighbourhood states. It is not clear that these frameworks are helpful or always much used in organizing EU relations, but the countries matter enormously for health in the world and for the EU’s action on health. The sheer diversity of neighbourhood countries, territories and areas means that there needs to be a multitude of tools to be effective. The EU Neighbourhood Policy is not a geographical expression, but rather a concrete policy vehicle originally developed to manage and strengthen relations with neighbouring states, territories and areas. To the south, that means Algeria, Egypt, Israel, Jordan, Lebanon, Libya, Morocco, occupied Palestinian territory, including East Jerusalem, the Syrian Arab Republic and Tunisia. To the east, neighbourhood policy states are Armenia, Azerbaijan, Belarus, Georgia, and Moldova. The sheer diversity of neighbourhood countries and territories means that one policy could hardly be relevant for all of them. In many cases, major political events have led to their relations with the EU becoming essentially bilateral, conducted outside any particular framework (Israel and Libya, for example) or essentially frozen (Belarus, the Syrian Arab Republic). The Russian Federation is not a neighbourhood policy state and while there have been efforts to forge cooperative relations in health, EU cooperation with the Russian Federation was stifled by Russian restrictions on civil society and health cooperation initiatives had largely ceased by 2022.EU relations with the Russian Federation are likely to remain difficult due to the repercussions of the Russian Federation’s war on Ukraine. Accession states receive financial and technical assistance as well as information from the EU to support them in the implementation of the acquis communautaire. Candidacy to EU accession is a particular status that follows application by the state in question and acceptance of that application by the Council. Once a state is a candidate for accession, negotiations begin on a wide variety of substantive chapters of the EU acquis communautaire, the body of EU law which every state must accept and implement in order to join the EU. In this they can receive financial and technical assistance as well as information from the EU. Not all candidates are equally enthusiastic about their EU applications or the domestic policies needed to advance, while EU Member States are not all equally enthusiastic about all the candidates’ applications. The result is that a number of significant EU relationships are with countries that are clearly not on a rapid path to accession but are still technically candidates and dealt with as such. Current accession candidates are Albania, Moldova, Montenegro, the Republic of North Macedonia, Serbia, Türkiye and, since June 2022, Ukraine. The southeast European candidates could join the EU, in principle, within a few years. Türkiye’s application is frozen and there seems to be little political will on either side to advance it. EU relations 19 European support for improving global health systems and policies with Türkiye on major issues, such as refugees, take place outside the accession framework. Ukraine’s candidate status, recent and awarded to a country defending its territorial integrity in a war, was politically momentous but the numerous technical details of accession, many of which touch on health, are just starting to be discussed. The EU should use its global voice for health. International partnerships based on co-ownership and co-responsibility are recentred in the Global Health Strategy. The Global Gateway would develop multilateral partnerships with countries that have similar global aims. Countries including the United States, United Kingdom, Japan and Canada have all been specifically identified, with partnerships between agencies such as the ECDC and American Centers for Disease Control (CDC) or African Union aiming to build resilient health systems and governance to prevent outbreaks. The EU Global Health Strategy addresses strains to health systems in neighbouring Ukraine and Moldova, as well as candidate countries. The Strategy specifies not only the need for ongoing European health system support, but also the need to extend health system aid through continuous partnerships. Global health action is used for and affected by geopolitical goals. The world outside the immediate environs of the EU is obviously diverse and complex, ranging from small states highly dependent on European aid to a range of great powers with varying patterns of cooperation and rivalry. Some noteworthy clusters of countries include great powers, which range from longstanding allies and partners such as the United States, Japan, United Kingdom and Canada, to powers such as Brazil, China, and India, whose relations with the EU are still in flux. The policy tools that are relevant in direct relations with them will vary considerably based on their gross domestic product (GDP) and the nature of their interactions with the EU; trade policy, for example, is a major feature of EU interactions with the United States, United Kingdom, Japan and Canada, and is a powerful tool to shape relations with them. Their goals can also lead them into direct competition with the EU as well as complementary relations. We see this, for example, in the history of Brazil’s efforts to build a domestic research-based pharmaceutical industry and consequent tensions with the EU, and within Brazil and the EU over IP and access to medicines issues (Massard da Fonseca & Moraes de Achcar, 2022). Geopolitical competition in health is often filtered through relations with third countries. ‘Vaccine diplomacy’ in 2020 and 2021 was a notable example (Jarman et al, 2024). Most countries with access to COVID-19 vaccines, including EU Member States, used vaccines as diplomatic tools with which to build relations with particular governments and acquire prestige in other countries. Box 5: Moving from Health in All Policies to Health for All Policies WHO’s Helsinki ‘Statement on Health in All Policies’ described HiAP as: “an approach to public policies across sectors that systematically takes into account the health implications of decisions, seeks synergies, and avoids harmful health impacts in order to improve population health and health equity” (PAHO, 2014). HiAP was the most important international movement to achieve health goals through intersectoral action. Health in All is a: “horizontal, complementary policy-related strategy contributing to improved population health. The core of HiAP is to examine determinants of health that can be altered to improve health but are mainly controlled by the policies of sectors other than health” (Ståhl et al., 2006). HiAP entailed intersectoral governance or multisectoral governance, “coordinated action that explicitly aims to improve people’s health or influence determinants of health. Intersectoral action for health is seen as central to the achievement of greater equity in health, especially where progress depends upon decisions and actions in other sectors” (Ståhl et al., 2006). While HiAP and the theory of working together to improve health is essential, the practicality of engaging other sectors has proven difficult. It is for this reason that an expansion of thought is required to move away from a unidirectional relationship (health sector benefiting from other sectors) towards a bidirectional one (both the health and other sectors benefiting from the collaboration). This bidirectional relationship, Health for All Policies (H4AP) highlights what the health sector can do for other sectors and vice versa (see Greer et al., 2022c for more details). For more information please refer to the European Observatory policy brief on Making Health For All Policies: Harnessing the co-benefits of health (Greer et al., 2023). 20 Policy brief 6. Conclusions That the EU shapes global health is unarguable and, since the Commission’s 2022 Global Health Strategy and the 2024 Council conclusions on global health, accepted. As a regulator, donor, market, research system and global voice, its policies shape the health of the globe and the world of global health. Sometimes its power comes from its influence on one of the world’s largest economies, the European internal market; sometimes that power comes from its direct policy actions. Much of its power could be used for ends that support global health, which matters to other policy goals because sustainable development and the SDGs depend on healthy populations. Even if they could go further (McKee et al., 2023), the Strategy and the 2024 Council conclusions on global health is a major step forward in appreciating and aligning the EU contribution (Kickbusch & Perez-Canado, 2023). There is no question that the EU affects global health; the question is what its global health approach should be as it extends and implements the 2022 Commission Strategy and the 2024 Council conclusions: what they should ultimately include, who should implement it, and to what ends. Moving closer to answering these questions requires developing a better understanding of the realm of sectors, policies, actors and initiatives which, willingly or not, exert an influence on health globally. This policy brief provides a first mapping of some of the EU policy areas relevant for global health. By highlighting how they support global health objectives and by providing concrete examples of the instruments and financial strands leveraged by the EU in each of these areas, we introduce a scalable and replicable conceptual stepping stone for future mapping exercises in other vital policy areas, such as climate change or food safety. Such exercises will be crucial to support the implementation of the priorities envisioned by the new Global Health Strategy as well as maximizing the effectiveness of available funding, building meaningful synergies across policy areas and monitoring efforts systematically as the 2024 Council conclusions call on the EU, member states, and partners to do. This policy brief demonstrates that, while it is challenging to pinpoint the numerous policies which shape health globally, it is also possible and useful. Understanding how different strands and instruments interact and assimilate is crucial to develop more coherent and complementary policies, as well as to reduce duplication and fragmentation of global health actions in the future. 21 European support for improving global health systems and policies As highlighted in Part I, this policy brief maps some of the most important EU instruments across five key policy areas relevant to global health amongst many other sectors, such as agricultural, environmental and migration policies. As policy areas relevant to health globally continue to emerge and develop, this mapping is not comprehensive, but rather serves as a foundation and first building block for further mapping and for developing an understanding of the various policy areas and instruments of importance to the 1. Trade in goods and services EU policies on trade in goods such as medicines and medical equipment, tobacco and armaments, have important distributional effects. The European Single Market is one of the world’s largest markets, and so how the EU governs trade can have an important impact on health in third countries. Trade is an important source of economic growth; if managed properly, it can support a healthy population or, if managed poorly, it can cause disruptions that impact health. Policy on trade in goods has important distributional impacts, affecting who can access, and afford, important products that support health, such as medicines, medical devices and equipment, or healthy food. Conversely, trade policy also affects the distribution of products that negatively affect health, such as tobacco products, armaments or unhealthy food. The EU’s approach to trade in services also has the potential to impact health. The provision of health services across national borders within the European Single Market illustrates these potential benefits and risks. Trade in health services, if well regulated, can potentially supplement national health care provision and provide economic benefits to the countries providing care, while obligations arising from trade agreements have the potential to limit cross-subsidization within health systems or restrict the health policy space (Koivusalo, Heinonen & Tynkkynen, 2021). The EU’s most recent trade agreements include ambitious commitments on liberalizing trade in services, counterbalanced in health by policy reassurances that trade agreements will not prevent governments from providing, supporting or regulating health services.1 The EU anticipates that trade in services between Member States and third countries will continue to grow in the coming years, and highlights the role of IP protections in supporting this growth (European Commission, 2021a). EU’s continued global health action. The following sections present each of the five policy areas covered, with pertinent examples of instruments and how they have been leveraged to improve health or advance global health goals to date. The policy areas that we have selected are important but by no means the whole of the EU’s considerable global health profile. Our approach shows the value of mapping policy tools and could be extended to a variety of other policy areas surrounding the 2022 EU Global Health Strategy. The EU institutions have exclusive competence to set trade policy on almost all trade-related topics, including trade in goods and services, the commercial aspects of IP, public procurement and foreign direct investment. Exclusive competence presents several opportunities for addressing global health issues through trade policy (see Box 6 for an example of trade policies with relevance to One Health). Policy Policy instruments used by the EU to govern trade in goods also apply to services, but the latter are shaped by the General Agreement on Trade in Services (GATS) as well. Trade agreements: The EU seeks to speak with ‘one voice’ in trade negotiations with third countries, giving it more leverage in trade negotiations than individual Member States would have alone. This is important for health because the way in which the EU incorporates core values, such as sustainable development, into its trade policy can influence practice in other countries. Chapters on trade and sustainable development (TSD) incorporated by the EU in its trade agreements, combined with diplomatic activities designed to improve compliance with agreements, have the potential to improve sustainability and health in both the EU and trading partner countries. Trade arrangements: The EU also takes many unilateral trade policy actions that have the potential to affect health in third countries. Several types of trade arrangement offered by the EU grant non-reciprocal, preferential terms of trade to third countries in order to influence the trading relationship in line with EU core values. The Generalised Scheme of Preferences (GSP)+, for example, aims to promote sustainable development and good governance in developing countries by offering advantages above and beyond the standard GSP. Third countries obtain trade benefits for complying with international agreements and conventions on human rights, labour rights, environmental protections and good Part II: Mapping EU global health policy 1 “EU trade agreements do not and will not prevent governments, at any level, from providing, supporting or regulating services in areas such as water, education, health, and social services, nor will they prevent policy changes regarding the financing or organisation of these services” (European Commission, 2015a). governance. Everything But Arms removes tariffs and quotas on goods except arms and ammunition for least developed countries (LDC). Consultation mechanisms: The EU Commission routinely consults with the public, Member States (in the form of expert groups), stakeholders and civil society groups when deciding upon and implementing trade policies, although global health issues are not frequently the focus of these consultations. The Civil Society Dialogue (CSD) provides a formal channel for information sharing and relationship building with civil society groups which goes beyond the ad hoc consultation mechanisms adopted by many other countries (Velut et al., 2022). The CSD aims to ensure that trade agreements are implemented in ways that do not run counter to the EU’s core value of sustainable development. DG TRADE also consults with civil society groups in third countries about the implementation of trade agreements through domestic advisory groups. Compared to major trading partners such as the United States, the CSD provides unusually strong representation for civil society, but civil society engagement is often too late in the process and the process does not allow it to counterbalance traditionally dominant business interests. Trade defence: The European Commission also has the ability to use various policy instruments to defend EU interest groups against trade distortions and non-compliance with the content of trade agreements. Use of trade defence measures occurs after investigation by DG TRADE and requires specific evidence about the trade distortion. Most defence complaints relate to technical trade matters. But, as of June 2022, EU stakeholder groups can raise issues of systematic non-compliance with TSD chapters or the GSP via the Single Entry Point, a single point of contact within DG TRADE designed to expedite complaints (European Commission Directorate-General for Trade, 2022). The definition of stakeholders is quite broad and includes Member States, businesses, industry and employer associations, trade unions, NGOs (including foreign organizations participating in domestic advisory groups), EU citizens and permanent residents. Policy reviews: In order to set a future strategic direction, the EU conducts regular reviews of its trade policy. The most recent review, ‘Trade policy review – an open, sustainable and assertive trade policy’, was published in February 2021 (European Commission, 2021a). The 2021 review envisions three core principles behind EU trade policy: the green and just transition, openness and assertiveness. The review also notes the importance of trade in health-related products in the context of the COVID-19 pandemic, where heightened demand and supply constraints came together to expose vulnerabilities in the health sector. Understanding and addressing such supply-chain issues, which have implications for health outcomes in both EU Member States and third countries, is an important part of supporting global health. In June 2021, the Commission also launched a ‘Trade and Sustainable Development Review’ with the aim of strengthening the contribution of EU trade agreements to sustainable development. In its Communication presenting its conclusions from the Review, the Commission states its support for including occupational safety and health in future TSD chapters, in line with a recent expansion of the International Labour Organization (ILO)’s core principles (EUR-Lex, 2022). Trade in services: Many of the policy instruments used by the EU to govern trade in goods also apply to trade in services. However, policies governing trade in services are construed slightly differently, shaped by the WTO’s GATS. Under the GATS, countries agree to shape the regulation of trade in services within their domestic borders in certain sectors only. Countries may also include limitations to the liberalization of services trade in their specific schedules. Such limitations on trade in health services have been a matter of much debate within the EU. 22 Policy brief Box 6: Transversal topics One Health: Technical standards on food and AMR One way in which the EU can affect global health through its trade policy is by setting sanitary and phytosanitary standards (SPS) for imports from third countries. The EU has developed extensive SPS, which regulate food safety, including fresh animal products, and establish rules on plant and veterinary health required for import into the EU (European Commission, undated, b). Meat and meat products are routinely monitored for residues of contaminating chemicals, pesticides and drugs, including antibiotics. As part of the EU’s response to AMR, which includes a One Health Action Plan against AMR and the Farm to Fork Strategy, two EU regulations were recently passed limiting the routine use of antibiotics to promote growth in farm animals, new rules which are also applicable to third countries wanting to import produce into the EU (European Commission, undated, c). Use of antibiotics in livestock represents one of the primary causes of AMR in humans, as residues found in meat are ingested and a large proportion of what is excreted is dispersed into the environment, including water sources (Ritchie, 2017; Van Boeckel et al., 2017). One Health approaches recognize the interconnectedness between humans, animals, plants, the environment they live in and their health. As highlighted in the recommendations issued by the Pan-European Commission for Health and Sustainable Development, instilling a One Health culture at different levels of government, across different sectors and structures, as well as supporting international and collaborative efforts that are conscientious towards such interdependencies is needed to mitigate future global health threats (Pan-European Commission on Health and Sustainable Development, 2021). For many countries, the EU represents the main market for selling and importing food products. By imposing technical standards that affect countries globally, the EU is able to promote safer agricultural and production practices, while also contributing to One Health objectives and the fight against AMR. One Health also plays a key role in the new Global Health Strategy, including plans to expand the existing European Antimicrobial Resistance Surveillance Network to deliver a more integrated surveillance mechanism to detect resistant pathogens, funded by EU4Health. 23 European support for improving global health systems and policies The GATS covers four modes of supply in which WTO members may choose to make commitments: cross-border supply of services; consumption abroad; commercial presence; and presence of natural persons. In the health care sector, these could correspond, for example, to the cross-border supply of health care in a country by a non-resident provider, the ability for the residents of one country to purchase health services within another country, a commercial health care provider establishing, operating or expanding health care provision in another country, and medical professionals moving to another country to provide health care services. Negotiations on trade in services and domestic regulations are ongoing within the WTO. In 2021, a group of 67 WTO members, including the EU, announced the conclusion of the Joint Initiative on Services Domestic Regulation, which aims to “simplify unnecessarily complicated regulations and ease procedural hurdles faced by SMEs in particular”. Because women entrepreneurs are an important part of the small and medium-sized enterprise (SME) sector, the agreement includes a novel binding provision on non-discrimination between men and women. Participants in the Joint Initiative are expected to finalize their schedule of specific commitments to facilitate trade in services within their markets by the end of 2022. Pre-finalization commitments for the EU have been formulated, although the documentation is not currently public. Funding and technical assistance As the largest contributor of Aid for Trade, the EU provides significant technical assistance and other support to low-income countries. Aid for Trade: The EU and its Member States constitute the largest contributor of Aid for Trade (AfT) worldwide, providing 38% of global AfT. The EU’s AfT activity, in line with the WTO AfT initiative, provides technical assistance, capacity building, budget support, blending (combining EU grants with loans or equity from public and private sources), and guarantees to provide support in areas including agriculture, energy infrastructure, transportation, and banking and financial services. Aid for Trade also includes the preferential trading arrangements offered to low-income countries outlined above, such as GSP+ and Everything But Arms. In line with the 2017 Joint EU Strategy on Aid for Trade, the EU aims to increase the proportion of AfT provided to LDCs from 15% to 25% by 2030 in order to improve their share of global exports (EUR-Lex, 2017). Information The EU conducts assessments and evaluations that seek to understand the impacts of its potential and existing trade policies. Analysis and assessment: The EU conducts, and contracts with outside parties to conduct, a variety of assessments and evaluations that seek to understand the impacts of its potential and existing trade policies. While some of these assessments are primarily focused on economic impact, others consider EU core values such as sustainable development. Sustainability impact assessments (SIAs) include assessment of social, environmental and human rights issues related to ongoing trade negotiations. SIAs aim to further the goals outlined in the EU’s Better Regulation Agenda, promoting transparency in regulation and centring consultation with civil society. The EU has a very mixed record on using impact assessments and the SIAs’ impact for sustainability and health could probably be much greater. Box 7: Stakeholders remain divided on the question of balancing intellectual property rights and access to medicines The question of how to balance the intellectual property rights (IPR) of EU-based pharmaceutical manufacturers with efforts to promote widespread access to medicines has long been a cause of conflict within the EU and globally. During the COVID-19 pandemic, India and South Africa asked the WTO to waive IPR for COVID-related technologies, treatments and vaccines, a flexibility included in the WTO Agreement on TRIPS. South Africa argued that temporary suspension of IPR would remove barriers to expanding the production of COVID-related treatments and vaccines, facilitating technology transfer to lower-income countries and improving affordability. Subsequent negotiations among the Quad states (India, South Africa, the United States and EU) over 20 months eventually produced a compromise position, confirmed at the 12th WTO Ministerial Conference in June 2022. The EU initially opposed South Africa and India’s request, claiming that there was no evidence that IPR were preventing access to COVID-related technologies and vaccines, before moving to support the final compromise agreement (Usher, 2020). EU Member States and interest groups remain divided as to the best course of action. While the compromise position has been welcomed by some, it has also been criticised by interest groups on both sides of the debate. Representatives of the EU’s pharmaceutical sector consider the position to be harmful to innovation in the sector, with a chilling effect on research and development, and characterize the agreement as unlikely to be effective in achieving its goals (Cleppe, 2022; Pistorova, 2022). Interest groups supporting access to medicines, by contrast, have expressed disappointment that the agreement only covers vaccines and not other COVID-related medicines and tools, and that the agreement does not cover all countries. They agree with their opponents that the agreement is likely to be ineffective in practice, as most of the IP-related barriers to access they document pertain to COVID treatments and tools rather than vaccines (Médecins sans Frontières, 2022). Some have also criticised the governance process for determining the EU’s position on IP and access to medicines (Corporate Europe Observatory, 2022). 24 Policy brief 2. Public investment and fiscal instruments The EU uses a myriad of instruments to stimulate growth and investments around the world. The EU commits considerable sums of money to stimulate growth and investment globally. Financial support is provided in different ways: from direct aid and budgetary support for the governments of countries near and far, to fiscal instruments like loans, blended finance and guarantees involving the EIB that help to attract investors to areas of the world where unstable conditions and markets heighten the risks of investment. The EU also participates in multilateral mechanisms such as the ACT-A and financial intermediary fund for PPR (both are discussed further in the section on ‘Solidarity, voice and multilateralism’). Finally, some EU financial tools are primarily destined for internal use but may have an important spillover effect on other regions of the world. The myriad of available instruments collectively form part of an overarching investment strategy, the Global Gateway. Policy The Global Gateway lies at the heart of the EU’s global investment strategy and comprises instruments of relevance for global health. The Global Gateway lies at the heart of the EU’s global investment strategy. It was announced in 2022 and is expected to facilitate global infrastructure development, including health infrastructure, and to mobilize up to 300 billion euros in investment worldwide between now and 2027. This investment spur will be catalysed by leveraging financial support from a range of EU instruments, including Global Europe, the Instrument for Pre-accession Assistance (IPA III), Interreg, InvestEU and the Connecting Europe Facility (European Commission, undated, a). Most of these instruments are scattered across different policy areas, including areas that are relevant for global health in their own right, such as the EU’s development, neighbourhood and enlargement policies. For this reason, tools such as Global Europe and IPA III are presented in further detail in subsequent sections of this policy brief, which discuss these respective policy areas. Others, like InvestEU, Interreg and the Connecting Europe Facility, are instruments primarily dedicated to investment in infrastructure and are therefore outlined in further detail here. Although it is not strictly part of the Global Gateway and it places a stronger focus on health initiatives for knowledge sharing and collaboration, EU4Health also provides funding for a range of relevant initiatives and is therefore featured here. Some of these instruments feature specific funding for non-EU countries, while others focus on European investment streams that may have spillover effects on other areas of the world. In addition, the new Global Health Strategy highlights the EU’s plans to explore the use of innovative financial instruments, including debt swaps and loan buy-downs, to trigger further investment for health systems in third countries (European Commission, 2022b). Box 8: The EU–Africa Global Gateway Investment Package includes health system strengthening among its areas of focus (European Commission, undated, d) As part of the Global Gateway strategy, an investment package worth 150 billion euros was announced at the European Union– African Union Summit held in February 2022. The package aims to propel public and private investment on the African continent in a range of areas, the main ones being: • promoting a green and digital transition • building more sustainable economic growth and creating jobs • strengthening health systems • improving training and education. The package is to be primarily delivered through a set of Team Europe initiatives (see text below for more information on these initiatives). In the area of health, the package strives to improve vaccination coverage, strengthen local manufacturing capacities and enhance access to vaccines and novel health technologies by 2030. In pursuit of these ambitions, the Team Europe initiative Manufacturing and Access to Vaccines, Medicines and Health Technologies (MAV+) is mobilizing 1 billion euros from the EU and Member States to strengthen competent African partner institutions, including the African Medicines Agency (AMA), the WHO technology transfer hub and the Partnership for African Vaccine Manufacturing, which is hosted by the Africa CDC (European Commission, 2022d). At national levels, investments serve to upscale local production and manufacturing power. Attracting investments from the private sector is also a central goal of the initiative. Since backing for this initiative is partly obtained through Global Europe, it is also mentioned in this brief’s section on ‘Official development assistance and humanitarian aid’. Further Team Europe initiatives in the areas of sexual and reproductive health and rights, public health capacity building and sustainable health security infrastructures with a One Health approach are on the agenda for implementation. Team Europe: What are Team Europe initiatives? Launched in 2020 to deliver a more systematic and concerted COVID-19 response, Team Europe is a collaborative effort powered by the most important EU development actors including the EU institutions, EU Member States, the EIB and the EBRD (European Commission, undated, e). Financial commitment to Team Europe has grown from an initial 20 billion euros to over 53 billion at the end of 2021 (EEAS, 2020; European Commission, undated, f). Its objectives have evolved, reaching far beyond the delivery of the immediate COVID-19 response, and now involve supporting the economic and social recovery from the pandemic. Team Europe initiatives (TEIs) are a range of flagship initiatives implemented by Team Europe. With funding from the Global Europe instrument and expertise from the Team Europe actors, TEIs aim to address urgent development issues and promote growth and prosperity (see Table 1 for further examples of TEIs funded under Global Europe in the section on ‘Official development assistance and humanitarian aid’) (European Union, undated, a). 25 European support for improving global health systems and policies Funding EU-funded projects can pursue diverse aims in the area of health, relevant to EU Member States, accession and other countries. EU4Health EU4Health is the EU’s health programme. Although not per se part of the Global Gateway strategy, it is the primary instrument dedicated to health initiatives within the EU and another instrument with potential spillover effects for third countries at the nexus between the EU’s internal and external health policies. With a financial portfolio of over 5 billion euros, EU4Health has undergone a substantial budgetary expansion from previous iterations. This budgetary expansion was in part prompted by the COVID-19 pandemic and is accompanied by a commitment to strengthen Europe’s preparedness and response capacities in view of future cross-border health threats. Funding is provided via grants and procurement procedures across a wide range of priority areas and is also accessible to third countries affiliated with eligible entities based in Member States. For example one of EU4Health’s work strands in 2023 is dedicated to crisis preparedness and provides financial support to the newly established Health Emergency Preparedness and Response Authority, as well as actions to tackle AMR, enhance cooperation with the WHO on crisis preparedness and One Health approaches to combat cross-border threats. Beyond the global collateral benefits of a strengthened EU preparedness infrastructure for health security, the 2023 work programme includes concrete plans to establish an integrated One Health surveillance system for cross-border pathogens, which will also take into account neighbouring countries (including Balkan, Mediterranean and eastern partnership countries) and other third countries of concern (European Commission, 2022e). Further projects of direct relevance for implementation of the new Global Health Strategy funded by EU4Health include the institution of a coordination system with the Member States and a monitoring strategy, including regular progress reports, to evaluate the implementation of envisioned priorities. Interreg Interreg is an instrument governed by and funded under the EU’s Cohesion policy (through the European Regional Development Fund) with a budget of 10.1 billion euros that promotes cross-border, transnational and interregional cooperation projects. Beyond financial support for projects, an important aspect of such cooperations is the exchange of expertise and technical knowledge across borders and regions (Interreg, 2022). The transnational branch of Interreg is particularly relevant to building bridges with surrounding non-EU countries as well as the so-called outermost regions, which include EU countries in other continents and their surrounding regions, and is complemented by Interreg projects funded through the Instrument for Pre-Accession Assistance (IPA) and the European Neighbourhood Instrument (ENI; now part of the instrument Global Europe, described in the section on ‘Official development assistance and humanitarian aid’) (Interreg, 2022). Interreg projects can pursue diverse aims in the area of health, such as, for instance, bolstering cross-border health care, addressing environmental determinants of health or improving access to medical and social care for populations in need. For instance, the Development of a Transcultural social- ethical-care model for dependent population in the Mediterranean basin (TEC-MED) project aims to develop a transcultural care model for ageing and marginalized populations in the Mediterranean basin who suffer from chronic diseases, requiring long-term care and social support. The project was supported with a 2.9 million euro EU contribution and expected to offer up to 30 000 people better access to social services in participating countries (Italy, Greece, Tunisia, Lebanon and Egypt). TEC-MED is just one of many projects implemented as part of ENI CBC Med, one of Interreg’s cross-border cooperations funded under the ENI in 2014–2020 (the ENI has now been incorporated in the new instrument, Global Europe, in the ongoing multiannual financial framework (MFF)) (ENI CBC MED, 2022). InvestEU The InvestEU programme is an instrument building on the 2015–2020 Investment Plan for Europe (also known as the Juncker Plan), which catalysed over 500 billion euros in investment. Its primary objective is to replicate the success of this prior investment plan across Europe for the 2021– 2027 period with plans to mobilize over 370 billion euros (European Union, undated, b). The programme consists of three pillars: the InvestEU Fund, a dedicated advisory hub and a portal. Outside the EU’s borders, third countries can participate and contribute to investments made through the InvestEU fund given that a specific agreement for participation in EU programmes already exists or is stipulated. The fund itself can support projects in third countries through financing and targeted investment if the partner entity is located in one or more Member States and the project only partly extends outside the EU (European Commission, undated, g). By including territories outside the EU, the InvestEU programme has a spillover effect with potential benefits for global health. Relevant investment priorities for this programme include the areas of social investment and skills, which cater towards health care and long-term care projects amongst others, and research, innovation and digitalization. The latter may, for instance, be relevant for investing in artificial intelligence or in supporting biotech entrepreneurs in putting their inventions on the market. EIB Global The European Investment Bank is the EU’s lending bank. It leverages investment across many policy areas, including climate action and health, and provides attractive lending conditions and tailored advisory services for EU Member States. Although approximately 90% of its activities are focused on the EU, the EIB also has a fairly new development arm, EIB Global, which is supporting the EU’s Global Gateway strategy by leveraging investments for third countries in cooperation with the European Commission. EIB Global supports partner countries across the world, including in the neighbourhood and enlargement 26 Policy brief regions, EFTA countries and the UK, as well as many partner countries across the African, Asian and American continents (EIB, 2023a). Key investment priorities of EIB Global of relevance to health include digital infrastructure in underserved regions to ensure better access to public digital services, such as digital health care, as well as building up vaccine production capacities (EIB, 2022). For instance, a new vaccine production facility is planned at the Institut Pasteur in Dakar (Senegal). The bank has also been exploring possibilities to partner with vaccine manufacturers and upscale production capacity in other locations across Africa (EIB, 2022). Most recently, a new financing partnership was announced between the bank, the European Commission and the Bill & Melinda Gates foundation (EIB, 2023b; European Commission, 2023a). Connecting Europe Facility The Connecting Europe Facility (CEF) is an instrument with a total budget of just over 30 billion euros (of which 1.6 billion are dedicated to its Digital stream; other streams include Transport and Energy but are less relevant to this policy brief), which aims to improve connectivity and boost digitalization across the EU (European Climate Infrastructure and Environment Executive Agency, undated; European Health and Digital Executive Agency, undated). Although it is currently mostly being used to support projects within the EU, it may have relevant spillover effects in surrounding regions. For example, the establishment of cross-border cloud infrastructure interconnections may extend to and improve digital health facilities in third countries (European Health and Digital Executive Agency, undated). Similarly, the digital stream of the Global Gateway strategy foresees CEF-funded deployment of transcontinental backbone networks, such as satellites and submarine cable connections, to strengthen the connectivity between the EU and other regions of the world (European Commission, 2022f). This is likely to substantially improve internet connectivity and possibly facilitate remote health services like telemedicine consultations across continents. Box 9: Transversal topics The digital transformation: Implementing digital solutions and reducing inequities Digital technologies hold the key to making health systems more efficient and sustainable for the future. Yet, digitalization is advancing at uneven paces in different areas of the world, while also giving rise to important ethical, legal and regulatory considerations that need to be acknowledged to ensure a successful and truly equitable digital transformation. Even at EU level, the adoption of digital health solutions across health systems is unequal, but experienced a significant push throughout the COVID-19 pandemic (Fahy & Williams, 2021). Furthermore, the availability of numerous financial instruments to support digital investments, including Digital Europe, the Recovery and Resilience Facility and the Connecting Europe Facility, is promoting the progressive implementation of digital solutions across the EU. Similarly, the process is facilitated by the introduction of EU data protection legislation (the General Data Protection Regulation, GDPR) and a recent proposal for the development of a European Health Data Space to enable the cross-border exchange and use of health-related data (European Commission, undated, h; GDPR.EU, undated). As highlighted earlier in this section, some EU tools hold the potential to positively affect digitalization processes in other regions of the world as well; for example, by funding transcontinental network connections with the potential to facilitate intercontinental telemedicine services. However, many LMICs are significantly lagging behind when it comes to implementing digital health solutions in their health systems and may lack even the most basic technologies. This and poor access to digital tools and internet connectivity in the general population represent important barriers to wielding digital tools for health. In this context, the EU can play a decisive role in supporting digitalization processes in LMICs, while ensuring that health inequalities are progressively narrowed instead of exacerbated (Kickbusch & Kökeny, 2022). As announced in the new Strategy, the EU aims to support the development and implementation of national and regional strategies in LMICs, one example being the upcoming African Union/African CDC digital health strategies (European Commission, 2022b). 27 European support for improving global health systems and policies 3. Official development assistance and humanitarian aid Development assistance, neighbourhood and enlargement policy ODA is a shared competence between the EU and Member States; jointly they are the largest donor of ODA worldwide. Official development assistance is a competence shared between the EU and its Member States. Consequently, most Member States have their own bilateral development programmes in addition to their participation in EU development policies and the multilateral commitments made at EU level (Steurs et al., 2018). In 2021, the EU and its Member States jointly donated 70.2 billion euros, accounting for 43% of global development assistance and representing the largest donor of ODA worldwide (Council of the European Union, 2022). Policy Health has been an important component of the EU’s development assistance, with the approach changing over time from disease-specific programmes to more comprehensive health systems strengthening. Health has long been considered an integral component of the EU’s development assistance. Particularly since the early 2000s, development assistance for health has increased, with large streams of funding flowing into a range of global initiatives born at the turn of the millennium, such as the Global Fund dedicated to fighting acquired immunodeficiency syndrome (AIDS), tuberculosis and malaria, and the Global Alliance for Vaccines and Immunisation (Hafner and Shiffman, 2013). Over time, there has been a gradual shift in interest from initiatives primarily focused on disease-specific programmes to more comprehensive health system strengthening (HSS) approaches in donor countries. Reasons for this have included, amongst others, concerns over slow progress in achieving health-focused millennium development goals (MDGs) (Hafner and Shiffman, 2013). Advising the planning of the EU’s development policy and the programming of its primary financial tools, is the European Consensus on Development, a statement which was first undersigned in 2005 and later renewed by the Council, Parliament and Commission in response to the adoption of the 2030 Agenda for Sustainable Development by the United Nations in 2015 (United Nations, 2015; Council of the European Union, 2017). This document outlines the EU’s strategic priorities and frames the common approach taken by Member States at the EU level with the aim of ensuring complementarity and coordination with their national development activities. The Consensus places a focus on five key themes, the so-called 5 Ps, which reflect the priorities expressed in the UN 2030 agenda and the concomitant SDGs: people, planet, prosperity, peace and partnership (Council of the European Union, 2017). Health is explicitly discussed as a dimension of the EU’s development efforts with a list of dedicated goals, the pursuit of which forms part of a comprehensive Health in All policies approach (see Box 5 for more information on Health in All policies). Key objectives with a focus on health include supporting: • health system strengthening, better access to services and UHC • health workforce training, professional development, recruitment and deployment • investing in frontline health care and social workers for delivery of care in underserved and isolated areas • prevention and treatment of communicable diseases including human immunodeficiency virus (HIV)/AIDS, tuberculosis, malaria and hepatitis, as well as epidemic outbreaks and AMR • addressing chemical pollution and poor air quality • prevention and treatment of non-communicable diseases, including mental health and further reducing child and maternal mortality rates. While support for disease-specific interventions continues to be provided through initiatives like the Global Fund (described earlier in this section), the document highlights the need to move towards more horizontal and cross- sectoral approaches. The Consensus describes numerous other areas of action with a direct relevance for global health, including efforts to strengthen social protection mechanisms and to achieve better gender equality, for instance through access to sexual and reproductive health care, or to enhance access to clean water and sanitation facilities for underserved populations, thereby contributing to the fight against infectious diseases. The EU continues to establish the importance of equitable care, as seen in Guiding Principles 1 and 2 of the EU Global Health Strategy, which aims to integrate various stakeholders into the mission to fight existing inequities in care (European Commission, 2022b). Beyond global development and diplomacy efforts, the EU’s foreign policy has also pursued distinguished priorities in its immediate neighbourhood through a dedicated Neighbourhood Policy, which currently applies to the 16 closest countries to the east and south of the EU and is delivered through the Eastern2 and Southern3 neighbourhood partnerships. The EU’s Neighbourhood Policy, which was reviewed in 2015, is focused on promoting the political, social and economic stability of its closest neighbours, including promoting good governance, rule of law and strengthening human rights (including access to health care) (European Commission, undated, g). 2 Countries in the Eastern neighbourhood partnership: Armenia, Azerbaijan, Belarus, Georgia, Republic of Moldova and Ukraine. 3 Countries in the Southern neighbourhood partnership are listed here: https://neighbourhood-enlargement.ec.europa.eu/european-neighbourhood- policy/southern-neighbourhood_en 28 Policy brief Priorities for the ongoing programming cycle include investing in the modernization of medical facilities and digital infrastructure, workforce training and improving access to health services and social protection systems, as well as bolstering preparedness and response capacities and setting up an EU vaccine-sharing mechanism (European Commission & High Representative of the Union for Foreign Affairs and Security Policy, 2020, 2021). Another group of countries endowed with a special status are those in the EU’s enlargement region,4 which receive additional financial and technical support tailored towards meeting the requirements for EU entry. This entails the adoption of all EU laws (acquis communautaire) and standards, including in the area of health (Greer et al., 2022b) (see Box 10 for further information). Financial support is delivered via the Instrument for Pre-accession Assistance (IPA III, MFF 2021–2027). IPA III has a budget of 14.16 billion euros for the financial period 2021–2027 and has been particularly instrumental to health during the COVID-19 pandemic, funding the provision of vaccine doses and activities to strengthen health system surveillance capacities (European Commission, 2022g). For example, within the scope of IPA III, a pre-accession support package worth 70 million euros was signed with Serbia in 2020 to support its development, but also to strengthen the country’s recovery and preparedness and response capacities for managing infectious diseases in the future (European Commission, 2020a). Box 10: EU accession candidates and neighbourhood receive financial and technical support towards adopting EU standards in the area of health EU health standards and related policies form an integral part of the legislative process and adaptations that (potential) candidate countries must implement in order to meet all the necessary conditions for EU membership. In particular, Chapter 1 on the free movement of goods and Chapter 28 on consumer and health protection of the acquis communautaire cover the specific legislative provisions to be transposed into national law in the area of public health. Technical support instruments, such as Twinning and Technical Assistance and Information Exchange (TAIEX; described below), are provided as an additional support to candidate countries to ensure that the necessary administrative and organizational arrangements are put in place for successful adoption of the required legislation (European Commission, undated, i, j, k). Some of the neighbourhood countries in the Western Balkans are already signatories of the EU’s joint procurement agreement, as well as benefiting from observer status in the EU’s Health Security Committee (European Commission, 2022b). Starting with the EU’s new MFF, most of the instruments used to implement these policies and strategic priorities (including the former European Development Fund (EDF) and ENI) have come together under a single umbrella instrument called Global Europe for the first time. Global Europe covers all EU funding for cooperation with third countries5 and unifies the financial tools dedicated to neighbourhood, development and international cooperation (NDICI) policies with a budget of 79.5 billion euros for the period 2021–2027 (European Commission, undated, l). Within the European Commission, which is in charge of administering and implementing instruments like NDICI– Global Europe, there are two main Directorates General responsible for putting into action the EU’s development and neighbourhood policies: the Directorate General for International Partnerships (DG INTPA) and the Directorate General for Neighbourhood and Enlargement Policy (DG NEAR). The commitment to human development outlined in the European Consensus on Development is reflected in DG INTPA’s strategic plan for 2020–2024, which governs how available financial instruments like Global Europe will be implemented. For example, the plan pledges at least 20% of funding from Global Europe towards human development initiatives. As highlighted above, health is considered to be a crucial dimension of human development. An important part of the funding dedicated to health is reserved for GAVI and the Global Fund, and monitored through performance indicators like child immunization and coverage of modern contraceptive methods. However, several other projects relevant to strengthening health systems and improving health are being funded by Global Europe and its predecessor programmes (see Table 1 for examples of funded projects) (European Commission, undated, m). Last but not least, an important component of the EU’s development policy relates to its participation in global partnerships. These include the Global Partnership for Effective Development Cooperation, which brings together multiple stakeholders including governments and multilateral organizations, to work together on enhancing the effectiveness of international development cooperation. Further partnerships include the UHC Partnership and UHC 2030 aimed at coordinating efforts across a range of different public and private sector stakeholders to achieve UHC and strengthen health systems globally. Further information on the EU’s involvement in multilateral cooperation and collaborative forums is provided in the section ‘Solidarity, voice and multilateralism’. Funding Global Europe is an umbrella instrument that unifies financial tools dedicated to neighbourhood, development and international cooperation. Global Europe: NDICI (European Commission, undated, l) Global Europe is a new comprehensive instrument made up of three pillars: • The geographical pillar provides support that is tailored to the specific needs of different regions, countries and local contexts. Its overall budget of 60.39 billion euros 4 Albania, Bosnia and Herzegovina, Kosovo,A Montenegro, North Macedonia, Serbia and Türkiye. 5 Except cooperation with overseas countries and territories, and the IPA III. All references to Kosovo should be understood to be in the context of the United Nations Security Council resolution 1244 (1999). 29 European support for improving global health systems and policies is distributed across the neighbourhood countries (19.32 billion), as well as countries in Sub-Saharan Africa (29.18 billion), Asia and the Pacific (8.49 billion) and the Americas and Caribbean (3.39 billion). • The thematic pillar, which zooms in on specific issues, provides dedicated funding of 6.36 billion euros for human rights and democracy, strengthening civil society, promoting stability and peace, and addressing specific global challenges, such as health, education, social protection and supporting marginalized populations including migrants, women and children. • Lastly, the rapid response pillar reserves 3.18 billion euros for unexpected events that require immediate interventions, such as crisis response and conflict prevention. Box 11: Global Europe’s 2021–2027 thematic multiannual indicative programme aims to address global challenges and is especially relevant to advancing health and global health priorities (European Commission, 2021b) Priorities for each of the different geographical regions supported through Global Europe are decided upon and defined in regional or country-specific multiannual indicative programmes (MIPs), which can address specific national and regional issues and/or encompass cross-cutting thematic objectives along the priorities defined in the programme’s thematic pillar (i.e., global challenges, human rights and democracy, civil society organizations, peace, stability and conflict prevention). These priorities are negotiated in close cooperation with national, regional and local authorities. Every year, the MIPs are implemented through annual action plans. Effectiveness of the implemented programmes is measured through predefined performance and result indicators, which are also adopted as part of the MIPs. The 2021–2027 thematic MIP aims to address global challenges and is especially relevant to advancing health and global health priorities. With approximately 1.8 billion euros pledged to human development projects, investment in and engagement with global initiatives like GAVI, the Global Fund, the WHO’s Universal Health Coverage Partnership and the UN Population Fund Supplies Partnership are reaffirmed as key priorities. The MIP also outlines current health gaps which the EU’s development and cooperation policies aim to tackle over the coming years, including improving universal access to basic health care, (COVID-19) vaccines and medical technologies, as well as promoting the recovery from the pandemic and ensuring that health gains achieved over decades of development assistance are not reversed as a result of the crisis. Other features of this new instrument include a flexibility cushion of 9.53 billion euros, which permits allocation of resources to unanticipated and new challenges, as well as an investment framework, which enables additional funds to be raised and mobilized from public and private sector investment. The latter entails the European Fund for Sustainable Development Plus (EFSD+), a successor programme to the European Fund for Sustainable Development (EFSD), which is backed by a budget guarantee of 53.45 billion euros, the External Action Guarantee. This instrument provides a set of financial mechanisms including loans, grants and guarantees to support potential investors by sharing the risk of investing and providing the financial backing needed to support sustainable development in those partner countries with more unstable markets or investment conditions (European Commission, 2021c). The EFSD+ also represents the main financial tool for raising global investments as part of the overarching Global Gateway Strategy (see section on ‘Public investment’). In addition to the above-mentioned financial mechanisms, the EU offers partner countries budget support, which consists of the direct transfer of funds to their national treasuries. This type of support is available to countries that are investing in national reforms to strengthen their public institutions and in capacity development aimed at achieving SDGs (see examples of projects financed with budget support, predecessor programmes such as the EFSD and the EDF, and other Global Europe streams in Table 1 below) (European Commission, 2021d). Technical assistance The primary aim of technical assistance is to strengthen the institutions and public authorities which administer funds and implement reforms in the recipient countries; such assistance has been used to propel reforms and build capacity in the health sector. The EU’s commitment to third countries is not limited to financial aid and investment. Technical assistance represents another component of the relationship and is delivered through a range of instruments tailored to the specific needs of different geographical regions. Their primary objective is to strengthen the institutions and public authorities that administer financial instruments like Global Europe and implement the reforms needed to move towards the SDGs. For instance, the Twinning instrument was specially developed to assist public administrations of EU accession candidates and countries in the neighbourhood with adopting EU legislation (Union acquis), as well as strengthening capacity and building institutional expertise. Support is delivered through peer-to-peer activities, such as workshops, training, study visits and expert missions involving public administration representatives (European Commission, undated, k). Another instrument, which can also be applied to countries outside the direct neighbourhood is called Technical Assistance and Information Exchange instrument (TAIEX-INTPA). This form of technical support entails peer-to-peer assistance with implementing structural reforms and development policies, and is provided to both public administrations and a range of other authorities, including law enforcement, trade unions and employers’ associations. Both instruments have been used to propel public health reforms and to ensure local administrative structures develop the necessary capacities to meet the health standards required to be considered for EU membership (European Commission, undated, j). Capacity building is also extended to the health workforce through programmes like the Mediterranean and Black Sea Programme for Intervention Epidemiology Training (MediPIET), which provides training for field epidemiologists, and contributes towards boosting knowledge sharing and regional cooperation in the Mediterranean region (ECDC, 2022b). 30 Policy brief Table 1: Examples of relevant initiatives funded by Global Europe and its predecessor programmes (EDF, EFSD) PROJECT/PROGRAMME SUPPORTED OBJECTIVES FURTHER INFORMATION Health‑related projects for human development Team Europe initiatives, e.g. Health in the Eastern Neighbourhood Vaccine preparedness and deployment programme aimed at: 4. distributing vaccine stockpiles equitably and to areas and populations in need 5. supporting and updating national vaccine deployment plans See ‘Health in the Eastern Neighbourhood’ in Team Europe Initiative and Joint Programming Tracker (European Commission, 2022h) Team Europe initiatives, e.g. Manufacturing and Access to Vaccines, medicines and health technology products in Africa (MAV+) Strengthening local manufacturing power for vaccines, pharmaceuticals and health technologies in African countries A similar approach will be pursued through the EU–Latin America and Caribbean partnership on local manufacturing of vaccines and health technologies, with a focus on enabling the transfer of new technologies, the development of regulatory frameworks and private sector engagement. See ‘Manufacturing and Access to Vaccines, Medicines and health technology products in Africa’ in the Team Europe Initiative and Joint Programming Tracker (European Commission, 2022d) See ‘EU Latin-America and Caribbean Partnership’ (European Commission, 2022i) See ‘Partnership on manufacturing vaccines, medicines and health technologies and strengthening health resilience in Latin America’ (European Commission, 2022j) Financial investment tools and Global Gateway European Health Platform (financed by EFSD, predecessor to EFSD+, in 2020) Guarantee of 438 million euros financed by the EIB to improve access to COVID-19 vaccines and diagnostics in Africa and the EU neighbourhood See ‘European Fund for Sustainable Development Plus’ (European Commission, 2023b) Collaborations between other EU agencies and partner countries EU for health security in Africa: ECDC4AfricaCDC (financed by EDF, predecessor to Global Europe, in 2020) Capacity-building project and partnership between the ECDC and Africa CDC to strengthen health security preparedness and response (including surveillance and data systems, outbreak response and emergency operations) See ‘EU for health security in Africa: ECDC4AfricaCDC’ (ECDC, 2022a) See ‘EU and AU sign partnership to scale up preparedness for health emergencies” (ECDC, 2020) Budget support to partner countries Peru: Improving access to child health services Budget support to develop a new child health service delivery model tailored to the needs of the indigenous population in the Peruvian Amazon. Results: After rollout of improved access to child health services for 25 000 children waiting times improved significantly from an average of 2 hours in 2018 to 20 minutes in 2020. See ‘Budget support: Trends and results 2021’ (European Commission, 2021d) Wallis and Futuna: Scaling up of telemedicine capacities Budget support to finance the island’s oceanic digital cable for broadband and the scaling up of telemedicine services on its territory. Results: In a population of 11 500 people, over 300 remote medical consultations were performed between 2019 and 2021. See ‘Budget Support: Trends and results 2021’ (European Commission, 2021d) 31 European support for improving global health systems and policies Humanitarian aid and civil protection The EU supports third countries in times of crisis and humanitarian disasters. In times of crisis and in the face of humanitarian disasters, the EU supports third countries through dedicated mechanisms overseen by the European Commission’s Directorate General for European Civil Protection and Humanitarian Aid Operations (DG ECHO). As the largest donor of aid in the world,6 the EU funds humanitarian aid projects on the ground, as well as pooling and deploying experts to support local response and recovery efforts in the aftermath of a crisis (United Nations Office for the Coordination of Humanitarian Affairs, 2022; European Commission, undated, n). To effectively implement the latter, DG ECHO also operates the EU Civil Protection Mechanism, which pools resources from the EU and other participating countries7 for a collective response to disasters and a coordinated transport of supplies and experts to affected regions worldwide. Policy Beyond providing immediate help, the EU’s humanitarian action also focuses on strengthening preparedness and response capacities. EU humanitarian action pursues three main objectives: to preserve life; to prevent and alleviate human suffering; and to maintain human dignity. The European Consensus on Humanitarian Aid is the policy statement (undersigned by the Member States, the Commission, the Parliament and the Council), which sets out a common vision and shapes the EU’s action framework since 2008 (EUR-Lex, 2008). The principles outlined in the Consensus were reaffirmed in the 2021 Commission Communication on the EU’s humanitarian action, which discusses the impact of and updates the actions proposed to respond to new challenges such as COVID-19, and climate change- and conflict-induced emergencies (European Commission, 2021f). Beyond securing and deploying essential medical supplies, an important aspect of the EU’s humanitarian action in the area of health entails strengthening preparedness capabilities and building up the capacity of fragile environments to respond to future crises. The role of multilateral engagement and the recognition of competent UN agencies and NGOs as key interlocutors and implementers in the field is equally central to the EU’s humanitarian aid philosophy. At the same time, the experience gained during the COVID-19 pandemic with initiatives like the EU Humanitarian Air Bridge (HAB) operations (see Box 13 for further information), which saw a direct engagement of the EU in the countries in need, has paved the way for a stronger EU involvement on site. Plans to build a European Humanitarian Response Capacity (EHRC), which now enables direct intervention and expands the delivery of humanitarian aid on the ground, were outlined in the 2021 Communication mentioned above. Further priorities highlighted in the Communication include increasing the flexibility of funding mechanisms and improving the continuity between humanitarian and development instruments to better face upcoming challenges and facilitate a territory’s longer-term recovery in the aftermath of a crisis. The Civil Protection Mechanism was established in 2001 to mount collective and coordinated responses to natural and anthropogenic disasters in the EU and countries participating in the mechanism. In case of need, countries Box 12: Transversal topics Numerous EU programmes reflect its commitment to promoting human rights and human development The COVID-19 pandemic has threatened to reverse many of the health and social gains attained through decades of multilateral development work and engagement of partner organizations on the ground. HIV testing and treatment rates have gone down, while gender-based inequalities, including poor access to health care and rates of (domestic) violence, have risen globally (Roberts, 2021; UN Women, 2021). The EU has demonstrated its commitment to promoting human development and protecting human rights over many years through a range of programmes and initiatives, of which many have received additional backing throughout the pandemic. A few examples of relevant initiatives are provided here: • Collectively, the European Commission and its Member States provide approximately 40% of the Global Fund’s total funding. As part of the Team Europe initiative, the European Commission pledged 150 million euros to the Global Fund’s COVID-19 response mechanism in May 2022, which supports LMICs in their pandemic response and aims to mitigate the negative impacts that COVID-19 has had on the fight against TB, HIV and malaria in these countries (Global Fund, 2022). • Equitable access to sexual health and reproductive health services is crucial to advancing health gains and to achieving gender equality. As part of the TEIs funded for human development, Team Europe is proposing the ‘Sexual and Reproductive Health and Rights (SRHR) in Sub-Saharan Africa’ initiative, which aims to raise SRHR on the political agenda and to turn it into an integral component of HSS and UHC approaches. It also aims to strengthen capacities for the supply and procurement of SRHR products across different regions and countries in Sub-Saharan Africa (European Union, undated, c). • Under Global Europe’s thematic pillar, the European Commission funds the Human Rights and Democracy programme worth 1.5 billion euros, which promotes human rights and democratic processes, and forges partnerships with chief institutions including competent regional and national institutions, the Office of the UN High Commissioner for Human Rights (OHCHR) and the International Criminal Court (ICC) (European Commission, 2021e). Recently, funding for the EU Human Rights Defenders Mechanism, a mechanism established as part of the programme, has been bolstered in response to an increase in requests for protection from human rights defenders and activists worldwide (European Commission, 2022k). 6 Combined EU and Member States’ funding. 7 Bosnia and Herzegovina, Iceland, Montenegro, North Macedonia, Norway, Serbia and Türkiye. 32 Policy brief can seek assistance from the mechanism’s coordinating centre, the Emergency Response Coordination Centre, which assembles the required support by connecting with civil protection authorities at national levels and subsequently coordinates the rollout of assistance, including teams of EU civil protection experts. Although primarily dedicated to helping participating countries, any country or organization (including UN agencies and other humanitarian organizations) can request assistance in case of emergency (European Commission, 2022l). In this context, EU humanitarian aid and civil protection frequently aim to function together through complementary efforts. Funding Humanitarian aid budgets support recovery from COVID-19. DG ECHO manages two separate budgets for humanitarian aid and the EU Civil Protection Mechanism, the latter having been allocated a total 3.3 billion euros for the next seven years (European Commission, 2022m). In turn, financing for humanitarian aid is decided upon on an annual basis, with a budget of 1.7 billion euros allocated to this cause for 2023 (European Commission, 2023c). The ongoing financial cycle (MFF 2021–2027) has seen both portfolios increase considerably compared to past iterations as a result of the temporary budgetary boost provided through new instruments like NextGenerationEU conceived to support the recovery from COVID-19. In addition, the Solidarity and Emergency Aid Reserve (SEAR) merges two instruments of reserve funding, which can be requested in case of unforeseen emergencies and crises prompting an EU-level response, including public health emergencies (European Commission, undated, o). The primary objective of these financial instruments is to deliver humanitarian aid to populations affected by natural and anthropogenic disasters, including delivering an immediate response after the occurrence of such an event (an example of this being the EU Humanitarian Air Bridge in Box 13) and developing longer-term support systems and coping strategies in fragile environments. Amongst other things, funding in 2022 was made available for activities pertaining to disaster risk reduction and preparedness, and the establishment of the EHRC (mentioned above). Since its inception, the EHRC has been instrumental in supporting the humanitarian response in Ukraine (see Box 13). Directly related to health, there is earmarked funding for epidemiological support provided by ECDC in the event of significant pandemic outbreaks (such as Ebola, COVID-19 or other diseases of equivalent severity). There are also plans to establish an EU Health Task Force at the ECDC to work closely with DG ECHO on strengthening country preparedness and to mobilize a coordinated response in the case of future health emergencies (Council of the European Union, 2021a). Box 13: EU Humanitarian Air Bridge as a prime example of humanitarian aid during COVID‑19 and the conflict in Ukraine The EU Humanitarian Air Bridge is an initiative that can be activated upon request, which started operating in the wake of the COVID-19 pandemic when international travel restrictions severely impacted humanitarian operations on the ground. Logistic challenges and shortages of essential medical supplies were mitigated by setting up flights to deliver humanitarian aid and specialized staff to areas in need. Since operations began, the HAB has already supported a wide range of countries and delivered thousands of tons of humanitarian and medical aid (European Commission, 2022n). The HAB forms part of a broader set of tools for delivering humanitarian aid in response to natural and man-made disasters, the EHRC (European Humanitarian Response Capacity, 2023). This set of tools brings together European stockpiles, different logistical services and experts (including health professionals), who can be deployed to support local responses. Technical assistance Medical reserves and capacity-building activities support crisis response in countries participating in the Civil Protection Mechanism and beyond. The European Civil Protection Pool collects ready-to-deploy resources from Member States and countries participating in the European Civil Protection Mechanism for immediate intervention and crisis response. As part of this pool, the Emergency Medical Corps mobilizes various types of medical reserves that have been pledged by EU Member States to the European Civil Protection Pool. Support provided includes workforce, such as health care experts and emergency medical teams deployable at short notice, as well as mobile biosafety laboratories and medical evacuation facilities, which may be distributed to territories affected by a health emergency. The Medical Corps was called into life after the Ebola epidemic in West Africa in 2014 and continues to participate in missions. For example, a measles outbreak in 2019 saw the deployment of emergency medical teams to Samoa to support the local response efforts (European Commission, 2021g). Deployment of medical teams is coordinated by the Emergency Response Coordination Centre, the operational heart of the Civil Protection Mechanism. Also available to all Member States, the countries participating in the Civil Protection Mechanism, and Enlargement and Neighbourhood countries, there is another technical instrument called the Peer Review Programme, which enables national civil protection authorities to assess their readiness to respond in a crisis and to identify gaps for improvement and bolstering of capacities. Throughout the readiness review process, a selection of experts from other participating countries produce a report which features context-specific recommendations for the country being analysed. In addition, the programme provides an opportunity for mutual learning and exchange of best practices across competent authorities (European Commission, undated, p). 33 European support for improving global health systems and policies 4. Solidarity, voice and multilateralism In early 2021, the EU announced a new strategy to strengthen the EU’s contribution to multilateralism. Multilateralism for the EU is an instrument that helps project European values and influence (Tocci, 2021). In terms of health, according to the European Commission’s communication on the EU Role in Global Health in 2010 mentioned previously in ‘Evolution of EU global health strategies’, this means that “the EU should apply the common values and principles of solidarity towards equitable and universal coverage of quality health services in all external and internal policies and actions” (European Commission, 2010). More specifically, the EU’s global health efforts can most clearly be seen in their collaborative spirit, i.e. with the Global Fund, GAVI, WHO, through its support of delegations operating in the health sector, and programmes to support public health institutes in partner countries, to name a few. This extends to a high level of explicit support for a stronger and more capable WHO, as explicitly addressed in Guiding Principle 14 and indirectly concluded in Principles 15, 16, 17 and 18 of the new EU Global Health Strategy (European Commission, 2022b). The EU interacts with various organizations and actively shapes its voice, role and position within that collaboration. At the beginning of 2021, the EU announced a new strategy to strengthen the EU’s contribution to multilateralism. The strategic priorities defined in the announcement included promoting peace and security, human rights and the rule of law, sustainable development, public health and climate. The EU has long since recognized that these priorities are not achievable alone. Recent policy efforts have encouraged stronger partnerships between the EU, the WHO and other multilateral and UN partners, as seen throughout this brief. Thus, the EU has promised to create more efficient coordination mechanisms between actors around these joint priorities, thereby making better use of the collective strength. As can be imagined, the EU works with a large number of different multinational actors. This section serves to highlight some of the most important cooperations. While recognizing the importance of and multitude of partnerships the EU has established with organizations in both the private sector and across civil society, this section focuses on the EU’s cooperation with its Member States and various multilateral forums operating in the global health arena. EU and the Member States While the EU plays a significant role in shaping global health policies, many of the Member States also pursue their own objectives on a bilateral level. While the EU plays a significant role in shaping global health policies, many of the Member States also pursue their own objectives on a bilateral level. Some Member States, such as Germany and France, have devised national global health strategies over the past decade (European Commission, 2021h; and see Steurs et al., 2017 for concrete examples). These bilateral relationships are important but can also be a source of tension between the Member States and the EU in case of diverging priorities and the possible duplication, or worse, fragmentation of efforts at national and union levels. The Strategy highlights the need to build purposeful synergies with all Member States, including pursuing upstream coordination with those countries that are not equally represented among multilateral forums such as the G7 or the G20 (European Commission, 2022b). As highlighted in ‘Official development assistance and humanitarian aid’, Team Europe includes the EU, its Member States, the EIB and EBRD and, since its creation in 2020 as a response to the COVID-19 pandemic, aims to improve the coordination and coherence efforts between partners (European Commission, 2023d). The primary goal is to make a sustainable recovery through building back better whilst achieving the SDGs through multilateral cooperations. In theory, the Team Europe initiative is a replacement for the former ‘flagship initiatives’ (WHO, undated, a) and can be formed at the country level or the regional level. The initiatives, however, must link to the priorities laid out in the MIPs (see European Commission, undated, m, for examples), which are directly linked to the global priorities of the EU. A practical example of how Team Europe has demonstrated a common EU voice can be found in the COVAX initiative. Box 14: ACT‑A AND COVAX brought together stakeholders in the fight against COVID‑19 The ACT-A (or Access to COVID-19 Tools Accelerator) was launched in April 2020 by the WHO, EU and several other global health organizations (WHO, undated, b). ACT-A brought together governments, scientists, civil society, charities and global health organizations with the following aims: • to accelerate development of COVID-19 vaccines, tests and treatments • to ensure equitable global access to them • to strengthen health systems. To achieve these aims, three partnership pillars were created (ACT-A, undated): 1. Diagnostics, Therapeutics and Vaccines (COVAX) 2. Health Systems and Response Connector (HSRC) 3. Access and Allocation workstream. COVAX stands for COVID-19 Vaccines Global Access and is the vaccines pillar of the ACT-A that was launched in September 2020. COVAX is co-led by the Coalition for Epidemic Preparedness Innovations (CEPI), GAVI and the WHO, along with UNICEF, a key delivery partner, and Team Europe, a key contributor (WHO, undated). The aim of this initiative is not only to accelerate the development and manufacture of vaccines, but also to guarantee the fair and equitable access of those vaccines worldwide. On the EU side, the EIB has also been a key financial contributor to COVAX (EIB, 2022). 34 Policy brief The EU and the G7 The EU plays an important role in influencing the G7 agenda. The EU is a non-enumerated member of the G7 and thus does not participate in the rotating presidency; however, it plays an important role in influencing the G7’s agenda. The development of the new EU Global Health Strategy (European Commission, 2022b) was announced at the G7 Development and Health Ministerial Meeting in May 2022 and is expected to steer the EU’s priorities until 2030 (European Commission, 2022a). One of the main goals of the Strategy is to improve the ability of health systems to respond to and prevent global health threats in coming years (European Commission, 2022b). The G7 has underlined the importance of health security several times, for example during the UK Presidency at the G7 meeting in 2021 where the Carbis Bay report was produced. The report speaks to advancing UHC and global health through strengthening health systems, preparedness and resilience, priorities which are clearly reflected in the new Global Health Strategy. In May 2022, G7 leaders met and agreed on a joint Pact for Pandemic Preparedness to strengthen pandemic readiness, including building a global network for stronger surveillance systems and strengthening pandemic response readiness (G7 Germany, 2022). The EU plays a longstanding role in HSS (European Commission, undated, q). Six pillars of aid were designed to help strengthen health systems: • Health service delivery – We help our partner countries provide quality health services in fit-for-purpose facilities. • Health workforce – We support them in training and hiring sufficient and qualified health workers. • Health information systems – We help them develop sound health information and spread it efficiently among their population. • Access to essential medicines – We help them ensure that everyone has access to essential medicines at an affordable price. • Health systems financing – We support them in defining adequate health financing policies. • Leadership and governance – We make sure their health system is managed in a way that meets the needs of people, based on political commitment and accountable leadership. The EU has a number of priorities in multilateral forums that touch on health. Although not directly related to health, the EU’s priorities with regards to global economic policy governance include enhancing public and private investment, ensuring tax fairness and transparency, and enabling free and fair trade. In terms of the G7’s foreign and security policy, the EU has made it a priority to support Ukraine after the Russian Federation’s invasion in February 2022. Support is primarily provided in financial form, but the EU and the G7 have also adopted sanctions and restrictive actions against the Russian Federation. Within the area of foreign policy and security, the EU is also leading an international response to the Syrian and broader Mediterranean refugee issues, which heavily affect it and do not offer easy and humane solutions (European Commission, 2015b). It has also set out a European Agenda on Security (European Commission, 2020b). The aim of the agenda is to tackle security threats as well as setting up a common multilateral effort directed at fighting terrorism, organized crime and cybercrime. The role of the EU in climate change culminates in the European Energy Union Strategy, wherein the EU has committed to the world’s most ambitious and legally binding reduction targets worldwide (European Commission, undated, r). The final G7 agenda area is that of development. Here, the EU has proven to be a leading financial contributor to achieving the SDGs. Food security is one of the biggest priorities for the EU in terms of development. As highlighted in the section on ‘Official development assistance and humanitarian aid’, support for food and nutrition security is primarily financed through the geographical and thematic programmes of Global Europe. The EU and the G20 Through its membership of the G20, the EU can influence other countries to commit to and follow its priorities. The EU is a full member of the G20, and although the G20 is less Eurocentric than the G7, the EU still has a considerable amount of influence. The G20 is seen as an important venue for the EU in its attempts to influence other countries to commit to and follow its priorities. These priorities include: responding effectively to the consequences of the coronavirus crisis; mobilizing resources to ensure universal and equitable access to COVID-19 vaccines; and, in parallel, supporting global recovery (European Commission, undated, s). Furthermore, it is believed that high compliance to G20 commitments would strengthen the EU’s voice in general as well as its influence over the G20 (European Economic and Social Committee, 2011). Concrete issues influenced by the EU and its Member States include inter alia, a stronger oversight of credit rating agencies, more rigid regulation of bankers’ bonuses, and an increase in resources for the International Monetary Fund (IMF) (Hodson, 2011; for more detail, see Amtenbrink et al., 2015). The G20 Pandemic fund builds on the 20221 Financial Intermediary Fund for Pandemic Prevention, Preparedness and Response, which was established by the World Bank with the support of the G20 in response to COVID-19 (World Bank, 2022a). The Pandemic Fund finances critical investments that strengthen pandemic prevention, preparedness and response capacities at national, regional and global levels. The predominant aim of the Pandemic Fund is to assist LMICs in strengthening PPR and to help them fill existing capacity gaps in core domains of the International Health Regulations (IHR). When the creation of the FIF was agreed upon in the summer of 2022, the EU facilitated a donor meeting to help prepare for its establishment. In addition, the European Commission, as well as several other organizations, committed funds in support of the FIF. The EIB is one of many pre-accredited 35 European support for improving global health systems and policies entities that will serve as an implementing partner for PPR. In November 2022 the Bali G20 summit launched it as the Pandemic Fund (World Bank, 2022b). Box 15: Declaring commitment to ending COVID‑19 and improving preparedness for future pandemics at the Global Health Summit 2021 In May of 2021, the EU co-hosted the Global Health Summit where G20 leaders adopted the Rome Declaration (Council of the European Union, 2021b). The declaration was “a commitment to a series of actions to end the COVID-19 pandemic and to better prepare for future pandemics”. The leaders agreed, inter alia: • to address the funding gap of the ACT-A and extend its mandate until the end of 2022 • to create interoperable early warning information, surveillance and trigger systems that cover new viruses and their variants • to ensure equitable access to vaccines and increase support to LMICs • that BioNTech/Pfizer (1 billion), Johnson & Johnson (200 million) and Moderna (around 100 million) would deliver 1.3 billion vaccines to low-income countries at no profit and to middle income countries at lower prices (via COVAX) and these companies pledged to do so • to invest in equipping Africa so that it can produce its own vaccines (via Team Europe) • that Team Europe would donate 100 million doses of vaccines to LMICs until the end of the year, in particular through COVAX and also invest to equip Africa to produce vaccines itself. The EU and the UN The EU works closely with the UN in the areas of development, human rights and humanitarian assistance. The EU and its Member States are, collectively, the largest financial contributor to the UN system (EEAS, undated). This applies not only to the standard budget, but also to the funding of ODA (as highlighted in previous sections) and peace-keeping missions. From a political standpoint, the EU works closely with the UN in the areas of humanitarian aid, development, human rights and humanitarian assistance. Geneva and New York are the main communication hubs for the coordination between both partners. In the area of human rights, the EU proposes resolutions and makes declarations on the protection and promotion of human rights and fundamental freedoms. In addition, the EU was pivotal in establishing and developing the system of UN Special Rapporteurs on human rights issues. Relative to sustainable development and the environment, the EU ensures that important UN conventions enter into force. With regards to humanitarian aid, DG ECHO has been funding and coordinating humanitarian missions, providing relief supplies and services in the form of food, medicines, fuel and medical and logistical experts since its founding in 1992 (more information on DG ECHO’s work is provided in the section on ‘Official development assistance and humanitarian aid’). Figure 2: 2013–2020 EU commitments to UN bodies Source: EEAS, undated. WFP 18.30% UNDP 14.38% UNICEF 12.35% UNHCR 11.26% FAO 6.81% IOM 8.21% UNRWA 4.86% UNOPS 4.35% WHO 2.94% IFAD 1.84% Other 14.70% 36 Policy brief While each of the EU countries is an independent member of the UN, they all support the UN’s foreign and security policy. The EU’s interests are coordinated with the main committees, subsidiary bodies and other bodies of the UN (UNRIC, 2021). Within the UN system, collaborations with the WFP, UNDP and WHO are particularly relevant for the EU’s Global Health Strategy. Perhaps the most relevant UN relationship is between the EU and the WHO. The two organizations have a longstanding strategic partnership in which they support countries in achieving the SDG 3 on good health and well-being including all other health-related targets within the SDG framework. The partnership works through regular high-level strategic dialogues, including the EU’s participation in the World Health Assembly, which lead to shared commitments towards strengthening health care systems, working towards the achievement of UHC, and improving capacities and responses to health emergencies across countries (WHO, 2022). During the COVID-19 pandemic, the WHO and EU created an even stronger working relationship under the Team Europe partnership, where their goal was to work together to end the pandemic and support the creation of more resilient health systems. Specifically, the EU engages in and with WHO resolutions on COVID-19 and is working to strengthen the WHO as well as the European Council’s proposal to form a global pandemic treaty (Bergner, 2023). Such a treaty would follow two earlier international legal instruments, which marked the EU’s support for the WHO. The first was the IHR created in 2005 in order to provide an overarching legal framework that defines countries’ rights and obligations in handling public health events and emergencies that have the potential to cross borders. The second is the Framework Convention on Tobacco Control (FCTC). This was the first international treaty negotiated under the auspices of the WHO and was developed in response to the globalization of the tobacco epidemic. It is an evidence-based treaty that came into force in 2005 and contains guidelines and requirements for the implementation of the most cost-effective tobacco control measures available. The EU and all of its Member States ratified the treaty reaffirming the right of all people to the highest standards of health. The new Global Health Strategy and the 2024 Council conclusions re-emphasize the EU’s support for a strong WHO at the core of the global health governance system. Securing the financial sustainability of the WHO is viewed as a key element of this. The Commission also seeks, as part of the Strategy, to have the EU become a formal observer of the WHO with full participation rights (European Commission, 2022b). There are many ongoing collaborations including in the area of universal health coverage and avenues for more concerted actions around One Health. One concrete example of an ongoing collaboration between the EU and the WHO is the so-called ‘Health Clusters’. The WHO and DG ECHO joined forces to relieve suffering and save lives in humanitarian emergencies. There are currently 31 Health Clusters/Sectors, wherein two are regional coordination mechanisms (Health Cluster, undated). The coordinators are responsible for facilitating and coordinating the health partners in relevant countries with the goal of delivering quality programmes and services to affected populations. Box 16: The Quadripartite Memorandum of Understanding (MoU): Avenues for collaboration on One Health In April 2022, an agreement between the Food and Agriculture Organization (FAO) of the United Nations, World Organisation for Animal Health, the WHO and the United Nations Environment Programme (UNEP) was tasked under One Health. This legal and formal framework is meant to provide a policy for cooperation that recognizes the animal–human–ecosystem interactions. The Quadripartite MoU will initially focus on: 6. AMR 7. emerging and endemic zoonotic diseases (including foodborne diseases) and information sharing 8. strengthening of health systems. The framework provides legal precedence for future One Health cooperations between these four stakeholders (FAO, 2022). The implementation of this legal framework is intended to lead to further initiatives, like the One Health Joint Plan of Action (2022– 2026), which aims to provide a framework for allocation of AMR resources (UNEP, 2022). This, among others, will lead to greater interconnectedness not only in health but across sectors. In its new Global Health Strategy, the EU highlights the importance of establishing strong ties and collaborations with the Quadripartite to support the implementation of Guiding Principle 11, “to apply a comprehensive One Health approach and intensify the fight against antimicrobial resistance” (European Commission, 2022b). A further example is the Universal Health Coverage Partnership to expand UHC. Launched in 2011, the WHO and the EU forged a multilateral commitment between global and country action to make health accessible and available for all. The EU is the largest contributor in terms of funding ($168 million) and collaboration (WHO, 2022). The EU is committed to helping the WHO achieve its goal of 1 billion more people benefiting from UHC by 2023 (European Commission, undated, t). Through this partnership, the EU supports 115 countries in Asia, Africa, Latin America and Europe, helping to ensure access to preventive, curative and rehabilitative health services of quality without financial hardship. Most countries within the WHO European Region offer UHC; however, many people within the region still have to pay out of pocket for needed health services and medication. In an effort to decrease the financial barriers to accessing health care services, the WHO Regional Office for Europe offers tailored policy advice and policy dialogues on key issues in health financing policy. The EU is also a significant financial supporter of the WHO’s Global Strategy and Plan of Action on Public Health, Innovation and Intellectual Property, which “aims to promote new thinking on innovation and access to medicines, as well as… provide a medium-term framework for securing an enhanced and sustainable basis for needs-driven essential health research and development 37 European support for improving global health systems and policies relevant to diseases which disproportionately affect developing countries, proposing clear objectives and priorities for R&D, and estimating funding needs in this area.” The Strategy and Plan of Action are very clearly designed to work with the TRIPS agreement and waiver provision, noting that the “Doha Ministerial Declaration on the TRIPS Agreement and Public Health confirms that the agreement does not and should not prevent members from taking measures to protect public health” (WHO, 2008). Another specific example can be found in the partnership for health in Europe between the WHO Regional Office for Europe, the European Commission and the European Union (European Commission, 2020c). The ambition of this partnership is to achieve the highest level of health and health protection, in line with the SDGs, most specifically SDG 3. There are five key priorities: 1. Strengthening health security against health emergencies and other threats. 2. Strengthening effective, accessible, resilient and innovative health systems. 3. Reducing the impact of non-communicable diseases, with a focus on cancer. 4. Promoting sustainable food systems and health. 5. Promoting health cooperation with non-EU-countries. The partnership aims to exchange information and best practices, consult with one another, coordinate activities, and consider joint actions and initiatives. A more concrete cooperation plan between the two partners is under development (WHO, 2022). Over the past few years, COVID-19 has been one of the top priorities on the EU’s and WHO’s agendas. In recent years, the top priorities on the EU and WHO agendas have been the COVID-19 pandemic response, health systems strengthening and UHC, access to medicines, health emergencies and humanitarian aid, global health security, One Health and health determinants. All link to the recognition that health knows no borders and that health security depends not on one country but all, as further cemented in the Global Health Strategy. As previously mentioned, the COVID-19 pandemic response was instituted as a collective project known as Team Europe, through which EU institutions collected 26 billion euros to aid countries and international partners in their response to COVID-19. Team Europe played a substantial role in the launching of the ACT-A wherein the COVAX partnership rests (see Box 14). This global cooperation platform unites governments, health organizations, NGOs and civil society to ensure access to COVID-19 tools, such as vaccines, tests and efforts to improve health systems (WHO, undated, b). Improving access to medicines falls under the Team Europe competencies through which the EU will continue to support the cause in advancing regulatory convergence, harmonization and use of reliance mechanisms, facilitating technology transfer and capacity building for local production, and improving governance, demand consolidation and strategic purchasing. These contributions are designed to help African partners create a sustainable foundation that ensures UHC as well as creating job opportunities for young African generations. Health emergencies and humanitarian aid are covered through DG ECHO where the EU supports the outbreak and crisis response operations of the WHO health emergencies programme worldwide. The partnership between the WHO and DG ECHO provides vital humanitarian relief and assistance to the most vulnerable and fragile communities that are particularly impacted by health emergencies (see the section on ‘Official development assistance and humanitarian aid’ for further information). The WHO and its Member States initiate resolutions at the World Health Assembly to strengthen WHO preparedness and response to health emergencies. These resolutions assist in gathering lessons from the pandemic in order to improve the systems and tools used for prevention, preparedness and response (WHO, 2021). The One Health approach is a cooperation between the EU and the WHO at the global, regional and national levels to address AMR (WHO, undated, d). The stated goal and focus of the cooperation is to assist countries in strengthening their capacities so that they may better prevent and control current and future global health challenges. Deepening the collaboration with the Quadripartite is one of the key actions highlighted in the new Strategy (see Box 16 for more information on the Quadripartite). Humanitarian action is a key strand of the EU and UN’s joint work. The World Food Programme (WFP) is the largest humanitarian organization working towards zero hunger and has been collaborating with the EU since 1996. Specifically through the financial support of the European Member States, the European Commission, DG ECHO (European Commission’s Civil Protection and Humanitarian Aid Operations), DG INTPA (European Commission’s Directorate-General for International Partnerships) and DG NEAR (European Commission’s Directorate-General for Neighbourhood and Enlargement Negotiations), several humanitarian logistics and supply-chain actions were able to be executed thereby helping to repair the global disruptions to the transport systems during the pandemic (WFP, 2020a). 38 Policy brief Box 17: Country examples of the EU’s collaboration with the World Food Programme Afghanistan One of the most timely examples of this collaboration can be found in Afghanistan, where the country is still suffering from the 2018 drought and more than 20 years of conflict. EU funding allowed the WFP to distribute food via mobile health teams in all- terrain trucks to displaced peoples, thereby reaching more than 150 000 malnourished children in remote areas of the country. In addition, social protection activities served families in the Western Badghis province, who are still struggling to overcome the persistent impact of conflict and insecurity (WFP, 2020b). Zambia EU support for the WFP allowed for cash assistance to 655 000 food-insecure people in various urban areas of Zambia. Through this support, the WFP was able to reach many more cities that had suffered not only from a two-year drought but were also plagued with high COVID-19 infection rates and the economic impacts resulting from the pandemic (WFP, 2020c). Priority was given to those depending on the informal sector along with those struggling to meet their food needs as a result of increasing prices and income loss. The United Nations Development Programme (UNDP) and the EU have been working together since 2004 and are currently cooperating to support countries in their aim to achieve the Agenda 2030 for Sustainable Development. The main goal of this multilateral cooperation is to work with partners in other countries in order to increase the resilience of people and their communities in order to restore infrastructure, provide basic services and create jobs. Examples of initiatives can be found in Yemen, where thousands of people have been given access to food, jobs and electricity, and in the Caribbean, where improved procedures have enabled better disaster preparedness (UNDP, undated). The EU and the Gates Foundation The EU also pursues priorities in health by cooperating with multiple stakeholders across the private sector and civil society, including private philanthropic organizations, such as the Gates Foundation. Beyond its collaboration with multilateral organizations and governments, the EU also pursues priorities in health by cooperating with actors from the private sector and civil society, including private philanthropic organizations. One of these important partnerships is with the Gates Foundation. The Bill & Melinda Gates Foundation is a non-profit organization founded by Bill and Melinda Gates at the turn of the 21st century. The EU and the Gates Foundation have collaborated with the stated aim of reducing poverty and improving health throughout the developing world (Bill & Melinda Gates Foundation, undated). One collaborative project was, for example, supporting health services in Africa. The Gates Foundation contributed 54 million euros to the External Investment Plan helping the EU efforts to strengthen diagnostic health services in Sub-Saharan Africa (European Commission, 2018). Another example of an important collaboration is the African drugs regulator, the African Medicines Agency, for which the EU, the Gates Foundation and other countries have provided financial support. Both institutions will invest 100 million euros over five years (until 2027) to assist Africa’s drug and vaccine production (Reuters, 2022). As highlighted in an earlier section of the brief, additional funding to strengthen the AMA is being disbursed within the scope of the Team Europe initiative MAV+ (see Box 8 for further details). Box 18: Transversal topics The European Green Deal has ambitious climate goals over the coming years To overcome the challenges of climate change and environmental degradation, the EU has created the European Green Deal. Within this deal, the EU has agreed to reduce its net greenhouse gas emissions by at least 55% by 2030. This agreement will also ensure: • no net emissions of greenhouse gases by 2050 • economic growth decoupled from resource use • no person and no place left behind. These goals will improve the well-being and health of citizens by providing a commitment to more public transport, healthy and affordable food, energy-efficient buildings, cleaner energy, future- proof jobs and a globally competitive and resilient industry. To achieve these goals, one third of the 1.8 trillion euro investment from the NextGenerationEU Recovery Plan as well as the EU’s seven-year budget will finance the deal (European Commission, undated, u). Moving forward: Multilateralism in Global Health Strategies. Since the 2010 Global Health policy statements, the EU has developed further understandings of the importance of partnerships in addressing the growing health concerns resulting from health crises, climate change and other rising biosecurity threats. The EU Agencies have served their duty in providing sectoral advice to Member States. However, given the nature of the health threats, partnerships that loop in stakeholders including EU Agencies, Member States and organizations outside the EU are growing in importance. Multilateralism externally is seen as partnerships with international organizations like the WHO and UN, but may also be seen in partnerships with civil society or private entities providing vaccines or aiding the supply chain. Regional partnerships with African, Asian, Latin and Caribbean countries are also highlighted in the hope of expanding training initiatives and pharmaceutical manufacturing. Europe is looking at new ways to pursue One Health, which inherently promotes multilateralism through recognizing factors such as the environment. The trend towards One Health has bled beyond agreements between various agencies and new strategies such as the One Health Joint Plan of Action. The EU Global Health Strategy outlined programmes that partner with multiple agencies to promote sustainable growth and participatory practices (UNEP, 2022). The Strategy aims at best utilizing funding mechanisms like the Global Gateway to achieve goals that range across its 20 Guiding Principles (European Commission, 2022b). Furthermore, the Strategy highlights focusing specifically on Team Europe’s partnerships, for instance with African partners to help build biosafety infrastructure; this ranges 39 European support for improving global health systems and policies from training to correct treatment of hazardous materials that may damage the environment (European Commission, 2022b). All of these initiatives will require action from various institutions and agencies to train individuals, build facilities, and ensure that environmental needs are being met. More than just donating money to particular causes in the area of global health, the EU has proven itself to be a pillar of dialogue, cooperation, facilitation and support. Whether devising responses to the global pandemic or assisting countries in the achievement of the SDGs, the EU has been a pivotal force working together with international organizations, EU Member States, nations and global institutions. The voice of the EU is clear: UHC and the achievement of the SDG are top priorities in not only strengthening health systems and their resilience, but also ensuring job opportunities in developing countries. 40 Policy brief 5. Research and training partnerships Research and training partnerships can be used by the EU Commission to pursue global health goals and Scientific Diplomacy. While there is a well-documented story of trade partnerships, the importance of Europe’s involvement in research and training partnerships cannot be understated. The EU pursues partnerships beyond economic and humanitarian efforts. This is seen across different types of support, ranging from policy such as the EU Global Health Strategy, to training programmes like the vocational education training (VET). These support types are seen as methods to promote economic equality as set out in the United Nations’ 2030 SDGs. Through VET and similar training programmes, the EU partners with countries to educate future health workers in roles that will continue the training cycle in the future global health workforce (EUR-Lex, 2020b). The EU Commission pursues research and training partnerships to support innovation and scientific excellence. As discussed in the section on the ‘European and Developing Countries Clinical Trials Partnership (EDCTP)’ below, Europe’s global health outreach has primarily focused on clinical research into vaccines, aimed at addressing the spread of communicable diseases. The well-known funding instrument Horizon Europe provides opportunities for researchers across fields to apply for funds pooled by the EU Commission. Research and training partnerships can be used by the EU Commission to bridge international borders and pursue global goals. Global research and partnerships provide opportunities for Europe to extend relationships in new and immersive ways to establish diplomacy and address necessary health needs. The EU Commission terms this ‘Scientific Diplomacy’. Scientific Diplomacy encapsulates the interface of scientific discovery and dissemination with diplomatic relations. There are three different ways in which science interfaces with diplomacy recognized by the European Commission. The first is in diplomatic actions or diplomacy for science, meant to facilitate scientific collaboration. This includes research funds for which global researchers can apply. Secondly, science for diplomacy sees science as an object of exchange for diplomats. In this way, Europe uses its exchange of research and innovation to help pursue global political partnerships outside of science. Thirdly, science in diplomacy involves decision makers taking research into account, and promoting the further incorporation of science in the EU’s policies (EEAS, 2022). Scientific Diplomacy in all areas has been used throughout different iterations of the EU’s research and training programme. A past example of the EU Commission seeking diplomacy is the S4D4C (or ‘Using Science for/in Diplomacy for addressing global Challenges’), which ended in April 2021. Funded by Horizon 2020 (the predecessor to Horizon Europe), S4D4C was intended to address global issues through social research that encourages training and networking. In opening these channels, the use of the knowledge and training allowed researchers to connect and progress their work, also contributing to informing the decisions of government officials (Meyer, 2021). The three differing strands weave together in Europe’s chosen partnerships. Partnering with a wide variety of countries inside Africa and Latin America, as well as with countries like, Canada, Japan, the United States and the United Kingdom, strengthens the global bonds with Europe and establishes policy platforms for funds and information to flow, further uninhibited by the presence of technology. These partnerships are discussed throughout this brief. Partnerships established in international collaboration are better set to pursue global initiatives such as the United Nations’ 2030 SDGs. International collaboration leads to programmes including the later-mentioned EDCTP to flourish as a partnership between Sub-Saharan African and European countries. This indicates another trend in health research and training partnerships: the expansion of European and African partnerships, informed by the 2020 European Commission goal of fostering relationships with African countries. In particular, a joint communication outlines the necessity of strategic African partnerships (European Union, 2020), in which health is no exception. Table 2: Examples of EU research and training partnership main instruments INSTRUMENT GOAL OF PROGRAMME Horizon Europe Funding Instrument meant to provide a centralized source of funding for research, training and innovation both in Europe and beyond EU–AU Partnership (see text below) Foster diplomacy and research partnerships between the European and African Unions Knowledge4Policy (see text below) European Information tool meant to open access to data, intended to mobilize people to inform policy making across Europe and the globe Funding Horizon Europe and NextGenEU are powerful funding tools that enable European researchers to promote science in diplomacy. A major force for Europe is its robust funding schemes. Multiple iterations within its powerful Horizon Europe and other NextGenEU funding tools provide opportunities for European researchers and promote the other strands of science in diplomacy. The 2021–2027 MFF focuses on major challenges. Beyond social health factors, global cooperation to further develop technologies persists. These technologies include surveillance mechanisms, medicines and vaccines, and digital technologies. Further development can occur in digital spaces as time progresses. Horizon Europe funds multiple successful programmes that spread health information and support virtual exchanges of information. Some examples are provided below. 41 European support for improving global health systems and policies Horizon Europe Horizon Europe acts as the EU Commission’s main programme for research and innovation. For the 2021–2027 period, a budget of 95.5 billion euros has been allocated to support research across sectors. A health research cluster that focuses on ‘Global Challenges and European Industrial Competitiveness’ lies under Pillar II. In part thanks to COVID-19 relief provided by NextGenEU, health is a focus for the funds. The impact of Horizon Europe on global connectedness and health spans wide. Statistics from a Horizon 2020 evaluation research piece estimated that in the previous period there had been a total of 1.5 million research collaborations spanning 150 countries (Kátay, Mosburger & Tucci, 2019). As a funding mechanism, Horizon Europe embodies diplomacy for science as a way to promote global training and partnerships. Many of the current goals of Horizon Europe focus on the expansion of deep research in health technologies. The Health Pillar of Horizon Europe provides broad goals, with the European Commission listing intervention areas spanning from environmental and social determinants of health to technologies to health care systems (European Commission, 2022o). European and Developing Countries Clinical Trials Partnership Promoting cross-border partnerships that address ongoing issues as well as form diplomatic ties is important. Within Horizon Europe exists the European and Developing Countries Clinical Trials Partnership, which aims to foster partnership between researchers in Sub-Saharan Africa and Europe. EDCTP began in 2003, initially to investigate vaccine solutions for communicable diseases including malaria and HIV. The partnership formed to bridge Sub-Saharan African and European scientists (Olesen, 2018; European Commission, undated, v). Thus, health technologies that prevent the spread of infectious and emerging diseases are at the forefront of EDCTP’s focus (EDCTP, 2022). Since its inception, EDCTP has expanded to support development of research and development beyond communicable diseases by supporting partnerships between private and public sectors (Tanner, 2017). Previously, the EU Commission has had two periods of this initiative, with it renewed for a third time in November 2021. The latest iteration of EDCTP3 again focuses on forming partnerships between European and African researchers (see the section on ‘The EU and the Gates Foundation’), with 1.8 billion euros provided to pursue the goal of preventing the spread of diseases as well as re-emerging infectious diseases. The first call for proposals was released in 2022. The ultimate goal is to support over 100 research institutes in 30 countries to develop at least two health technologies fighting infectious or emerging diseases. As Europe moves into the third EDCTP initiative, the focus will begin to shift on providing greater capacity for those outside of Europe. EDCTP3 will promote Africa-driven research (EDCTP, 2021, 2022), further emphasizing Europe’s ability to promote global health while also acknowledging the voice of its partners. As the flagship global health initiative, EDCTP has developed Europe’s work in global health. Beyond providing funding for clinical trials, EDCTP’s progressive framework focuses on capacity building for researchers of all types, and provides programmes centred on ethics and training in an effort to expand the research network with its partner countries. The ECDTP’s 2021 annual report highlighted that the programme had provided training for over 150 epidemiologists and biostatisticians (EDCTP, 2021, 2022). The strengths of EDCTP lie in the partnerships made between Europe, Africa and interlocutors such as GAVI and Médecins Sans Frontières. The reach of the programme continues to expand, with the latest iteration adding three Sub-Saharan countries to the outreach. Partner countries continue to see the use of investing, as the budget has continued to increase with additional renewals (EDCTP, 2022). Marie Sklodowska‑Curie Actions Training researchers and the staff of tomorrow is another asset of training partnerships. The Marie Sklodowska-Curie Actions programme funds staff exchanges from academic, research, business and other knowledge-garnering institutions. Within the actions, global exchanges are highly encouraged, with the only constraint being that: 1) the exchange needs to occur between at least three organizations; 2) at least two of the organizations must Table 3: Examples of initiatives supported by Horizon Europe 2021–2027 PROJECT/PROGRAMME SUPPORTED OBJECTIVES TYPE OF SUPPORT European and Developing Countries Clinical Trials Partnership (EDCTP) Joint partnership between Europe and Africa intended to strengthen relations while developing health technologies Funding Marie Sklodowska-Curie Actions Staff exchanges action, in which three or more countries can apply to have staff exchanges funded Technical assistance (For further information, go to the Annex section of this brief.) come from EU Member States or countries in the Horizon Europe programme; and 3) if the organizations are from the same sector, one organization must come from a non-associated third country. If a non-associated third country is not on the list, the country may apply for exceptional funding if the project expects to provide expertise or accessibility to areas of research, whether due to infrastructure or placement, previously inaccessible. In these cases, cofinancing mechanisms meant to complement funding may also be an option. Several health-related projects have been funded by this initiative, many of which are multi-year projects. Given that the health sector is featured among the main pillars of Horizon Europe, many projects are within the wide span of health. A few related to health training include BioTrib Advances Training (for Biotribology of Natural and Artificial Joints, with partners in Europe, the United Kingdom and China), PregnancyAD, and VIROINF (meant to help researchers understand virus–host interactions) (European Commission, 2022p). Many of these are ongoing with funding continuing to anywhere between 2023 to 2026. Information New EU programmes support the virtual exchange of information creating access for global contributors. One of the largest trade partners is also a major information and technical partner: Africa. The popular EU–AU Partnership provides many programmes that promote scientific diplomacy through science for diplomacy and diplomacy in science. New programmes support the virtual exchange of information. There are multiple formats that this could take. A recent initiative that displays the European Commission’s potential is Knowledge4Policy (see Table 2) (European Commission, undated, w). This is an effort produced to create a knowledge base through which researchers may submit and share data and findings with the online community. Being in the virtual format allows global contributors access. Providing a knowledge base allows for science in diplomacy, giving a centralized source of information where policy makers can look for information. Since launching in April 2022, Knowledge4Policy has already attracted many health researchers. As of September 2022, there are over 1300 publications that appear related to health. Forty-six datasets have been added to the database. Within the overall Knowledge4Policy, there are initiatives to provide health researchers with health data; for instance, the Knowledge Centre for Bioeconomy exists within the framework to promote better information for bioeconomy-related policy-making (European Commission, 2022q). The Knowledge Centre for Global Food and Nutrition Security provides a knowledge service that displays Europe’s discussion of equal access to food and nutrition, with the database providing further backup for inter-policy dialogue (European Commission, undated, x). Technical assistance An important form of technical support comprises training of the global health workforce. The EU has a long history of supporting technical assistance and training, and instruments that allow sharing of tasks across borders are beginning to see more funding. Examples of partnerships involving support from European diplomats occur to promote technical assistance. Vocational training has been a refocus of EU partnerships, with programming to train additionally needed staff in partner countries and organizations, as seen in the Opportunity Driven Vocation Training Team Europe initiative. This partnership occurs in conjunction with the Manufacturing Pharmaceuticals with Africa; a similar manufacturing agreement with the Latin and Caribbean areas is currently in the works and will function as an initiative to promote bilateral agreements and address the ongoing concerns on AMR (Principle 17) (European Commission, 2022b). Box 19: Transversal topics EU action against a global health workforce crisis There is a shortage of health workers around the globe with severe consequences for access to and quality of health services. A health workforce crisis has been diagnosed by the widely acknowledged World Health Report 2006 (WHO, 2006). Some progress has been made in addressing this situation, but COVID-19 has again put massive pressure on the global health workforce. It is estimated that the EU alone will need 11 million newly trained or imported health and long-term workers to satisfy the rising demand in the health and long-term care sectors between 2018 and 2030. To avoid brain-drain from countries with critical workforce shortages, the EU and its Member States adhere to the WHO Global Code of Practice on the International Recruitment of Health Personnel. The EU also has an important role to play in the retention, training and development of health workers in countries, to strengthen the health workforce elsewhere. Concerns over the global health workforce, and the need for a sustainable infrastructure to support it, have been further reinstated. A global workforce is essential to strengthening the health system, the second priority within the EU Global Health Strategy. Guiding Principle 6 provides further context for research and training. The EU and its future partnerships aim to prioritize new opportunities for research and digitalization of technologies, such as artificial intelligence, as research priorities and tools. 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Antimicrobial resistance (https://www.who.int/health-topics/antimicrobial- resistance, accessed 13 September 2022). 50 Policy brief 51 European support for improving global health systems and policies World Bank (2022a). Financial Intermediary Fund for Pandemic Prevention, Preparedness and Response – Engagement and Overview (https://projects.worldbank.org/ en/projects-operations/products-and-services/brief/ financial-intermediary-fund-for-pandemic-prevention- preparedness-and-response-engagement, accessed 10 October 2022). World Bank (2022b). G20 hosts Official Launch of The Pandemic Fund (https://www.worldbank.org/en/news/ press-release/2022/11/12/g20-hosts-official-launch-of- the-pandemic-fund, accessed 21 January 2024). World Bank (2023a). The Pandemic Fund (https://www.world bank.org/en/programs/financial-intermediary-fund-for- pandemic-prevention-preparedness-and-response-ppr-fif, accessed 20 September 2023). World Bank (2023b). World Bank Country and Lending Groups (https://datahelpdesk.worldbank.org/knowledge base/articles/906519-world-bank-country-and-lending- groups, accessed 20 September 2023). 52 Policy brief Annex: Mapping of policy areas and instruments EU Global Health Strategy’s 20 Guiding Principles (European Commission, 2022b). 1. Prioritize tackling the root causes of ill health, paying particular attention to the rights of women and girls, and to vulnerable populations and disadvantaged groups. 2. Improve equitable access to a full range of essential health services from health promotion to disease prevention and affordable quality treatment, rehabilitation and palliative care to fight communicable and non- communicable diseases. 3. Improve primary health care with built-in surge capacity, and enhance core public health capacities to meet the requirements of the International Health Regulations. 4. Foster digitalization as a fundamental enabler. 5. Boost global health research to develop the technologies and countermeasures which are necessary to improve health. 6. Address workforce imbalances and foster skills. 7. Strengthen capacities for prevention, preparedness and response and early detection of health threats globally. 8. Work towards a permanent global mechanism that fosters the development of and equitable access to vaccines and countermeasures for low- and middle- income countries. 9. Negotiate an effective legally binding pandemic agreement with a One Health approach and strengthened International Health Regulations. 10. Build a robust global collaborative surveillance network to better detect and act on pathogens. 11. Apply a comprehensive One Health approach and intensify the fight against antimicrobial resistance. 12.Link effectively all policies and measures that have an impact on global health within the Commission, EU agencies and EU financing institutions. 13. Better link and coordinate policies and measures of the EU and its Member States to speak with one voice and deliver effective action worldwide. 14. Support a stronger, effective and accountable WHO. 15. Steer the new global health governance by filling gaps and ensuring coherence of action. 16. Ensure a stronger EU role in international organizations and bodies. 17. Expand partnerships based on equal footing, co-ownership, mutual interest and strategic priorities. 18. Strengthen engagement with key global health stakeholders. 19. Enhance EU finance for global health with maximum impact. 20. Assess progress and ensure the accountability of the EU’s global health action through permanent monitoring and assessment. The Policy Brief Series 1. How can European health systems support investment in and the implementation of population health strategies? David McDaid, Michael Drummond, Marc Suhrcke 2. How can the impact of health technology assessments be enhanced? Corinna Sorenson, Michael Drummond, Finn Børlum Kristensen, Reinhard Busse 3. Where are the patients in decision-making about their own care? Angela Coulter, Suzanne Parsons, Janet Askham 4. How can the settings used to provide care to older people be balanced? Peter C. Coyte, Nick Goodwin, Audrey Laporte 5. When do vertical (stand-alone) programmes have a place in health systems? Rifat A. Atun, Sara Bennett, Antonio Duran 6. How can chronic disease management programmes operate across care settings and providers? Debbie Singh 7. How can the migration of health service professionals be managed so as to reduce any negative effects on supply? James Buchan 8. How can optimal skill mix be effectively implemented and why? Ivy Lynn Bourgeault, Ellen Kuhlmann, Elena Neiterman, Sirpa Wrede 9. Do lifelong learning and revalidation ensure that physicians are fit to practise? Sherry Merkur, Philipa Mladovsky, Elias Mossialos, Martin McKee 10. How can health systems respond to population ageing? Bernd Rechel, Yvonne Doyle, Emily Grundy, Martin McKee 11. How can European states design efficient, equitable and sustainable funding systems for long-term care for older people? José-Luis Fernández, Julien Forder, Birgit Trukeschitz, Martina Rokosová, David McDaid 12. How can gender equity be addressed through health systems? Sarah Payne 13. How can telehealth help in the provision of integrated care? Karl A. Stroetmann, Lutz Kubitschke, Simon Robinson, Veli Stroetmann, Kevin Cullen, David McDaid 14. How to create conditions for adapting physicians’ skills to new needs and lifelong learning Tanya Horsley, Jeremy Grimshaw, Craig Campbell 15. How to create an attractive and supportive working environment for health professionals Christiane Wiskow, Tit Albreht, Carlo de Pietro 16. How can knowledge brokering be better supported across European health systems? John N. Lavis, Govin Permanand, Cristina Catallo, BRIDGE Study Team 17. How can knowledge brokering be advanced in a country’s health system? John. N Lavis, Govin Permanand, Cristina Catallo, BRIDGE Study Team 18. How can countries address the efficiency and equity implications of health professional mobility in Europe? Adapting policies in the context of the WHO Code and EU freedom of movement Irene A. Glinos, Matthias Wismar, James Buchan,Ivo Rakovac 19. Investing in health literacy: What do we know about the co-benefits to the education sector of actions targeted at children and young people? David McDaid 20. How can structured cooperation between countries address health workforce challenges related to highly specialized health care? Improving access to services through voluntary cooperation in the EU Marieke Kroezen, James Buchan, Gilles Dussault, Irene Glinos, Matthias Wismar 21. How can voluntary cross-border collaboration in public procurement improve access to health technologies in Europe? Jaime Espín, Joan Rovira, Antoinette Calleja, Natasha Azzopardi-Muscat, Erica Richardson,Willy Palm, Dimitra Panteli 22. How to strengthen patient-centredness in caring for people with multimorbidity in Europe? Iris van der Heide, Sanne P Snoeijs, Wienke GW Boerma, François GW Schellevis, Mieke P Rijken. On behalf of the ICARE4EU consortium 23. How to improve care for people with multimorbidity in Europe? Mieke Rijken, Verena Struckmann, Iris van der Heide, Anneli Hujala, Francesco Barbabella, Ewout van Ginneken, François Schellevis. On behalf of the ICARE4EU consortium 24. How to strengthen financing mechanisms to promote care for people with multimorbidity in Europe? Verena Struckmann, Wilm Quentin, Reinhard Busse, Ewout van Ginneken. On behalf of the ICARE4EU consortium 25. How can eHealth improve care for people with multimorbidity in Europe? Francesco Barbabella, Maria Gabriella Melchiorre, Sabrina Quattrini, Roberta Papa, Giovanni Lamura. On behalf of the ICARE4EU consortium 26. How to support integration to promote care for people with multimorbidity in Europe? Anneli Hujala, Helena Taskinen, Sari Rissanen. On behalf of the ICARE4EU consortium 27. How to make sense of health system efficiency comparisons? Jonathan Cylus, Irene Papanicolas, Peter C Smith 28. What is the experience of decentralized hospital governance in Europe? Bernd Rechel, Antonio Duran, Richard Saltman 29. Ensuring access to medicines: How to stimulate innovation to meet patients’ needs? Dimitra Panteli, Suzanne Edwards 30. Ensuring access to medicines: How to redesign pricing, reimbursement and procurement? Sabine Vogler, Valérie Paris, Dimitra Panteli 31. Connecting food systems for co-benefits: How can food systems combine diet-related health with environmental and economic policy goals? Kelly Parsons, Corinna Hawkes 32. Averting the AMR crisis: What are the avenues for policy action for countries in Europe? Michael Anderson, Charles Clift, Kai Schulze, Anna Sagan, Saskia Nahrgang, Driss Ait Ouakrim, Elias Mossialos 33. It’s the governance, stupid! TAPIC: a governance framework to strengthen decision making and implementation Scott L. Greer, Nikolai Vasev, Holly Jarman, Matthias Wismar, Josep Figueras 34. How to enhance the integration of primary care and public health? Approaches, facilitating factors and policy options Bernd Rechel 35. Screening. When is it appropriate and how can we get it right? Anna Sagan, David McDaid, Selina Rajan, Jill Farrington, Martin McKee 36. Strengthening health systems resilience: key concepts and strategies Steve Thomas, Anna Sagan, James Larkin, Jonathan Cylus, Josep Figueras, Marina Karanikolos 37. Building on value-based health care Peter C Smith, Anna Sagan, Luigi Siciliani, Dimitra Panteli, Martin McKee, Agnès Soucat, Josep Figueras 38. Regulating the unknown: A guide to regulating genomics for health policy-makers Gemma A Williams, Sandra Liede, Nick Fahy, Kristiina Aittomaki, Markus Perola, Tuula Helander, Martin McKee, Anna Sagan 39. In the wake of the pandemic: Preparing for Long COVID Selina Rajan, Kamlesh Khunti, Nisreen Alwan, Claire Steves, Trish Greenhalgh, Nathalie MacDermott, Anna Sagan, Martin McKee 40. How can we transfer service and policy innovations between health systems? Ellen Nolte, Peter Groenewegen 41. What are the key priority areas where European health systems can learn from each other? Johan Hansen, Alexander Haarmann, Peter Groenewegen, Natasha Azzopardi Muscat, Gianpaolo Tomaselli, Mircha Poldrugovac 42. Use of digital health tools in Europe: Before, during and after COVID-19 Nick Fahy, Gemma A Williams, COVID-19 Health System Response Monitor Network 43. European support for improving health and care systems Nick Fahy, Nicole Mauer, Dimitra Panteli 44. What are patient navigators and how can they improve integration of care? Hannah Budde, Gemma A Williams, Giada Scarpetti, Marieke Kroezen, Claudia B Maier 45. What are the implications of policies increasing transparency of prices paid for pharmaceuticals? Erin Webb, Erica Richardson, Sabine Vogler, Dimitra Panteli 46. How can skill-mix innovations support the implementation of integrated care for people with chronic conditions and multimorbidity? Juliane Winkelmann, Giada Scarpetti, Gemma A Williams, Claudia B Maier 47. Addressing backlogs and managing waiting lists during and beyond the COVID-19 pandemic Ewout van Ginneken, Sarah Reed, Luigi Siciliani, Astrid Eriksen, Laura Schlepper, Florian Tille, Tomas Zapata 48. Does provider competition improve health care quality and efficiency? Luigi Siciliani, Martin Chalkley, Hugh Gravelle 49. Health system performance assessment: A primer for policy-makers Dheepa Rajan, Irene Papanicolas, Marina Karanikolos, Kira Koch, Katja Rohrer- Herold, Josep Figueras 50. Making Health for All Policies: Harnessing the co-benefits of health Scott L. Greer, Michelle Falkenbach, Luigi Siciliani, Martin McKee, Matthias Wismar, Praneetha Vissapragada, Marie C. Montás, Janamarie Perroud, Olivia Rockwell, Josep Figueras 51. How can the EU support sustainable innovation and access to effective antibiotics? Michael Anderson, Dimitra Panteli, Elias Mossialos 52. Global Health Workforce responses to address the COVID-19 pandemic Margaret Ziemann, Candice Chen, Rebecca Forman, Anna Sagan, Patricia Pittman 53. What can intersectoral governance do to strengthen the health and care workforce? Margaret Caffrey, Tara Tancred, Joanna Raven 54. What steps can improve and promote investment in the health and care workforce? Barbara McPake, Prarthna Dayal, Julia Zimmermann, Gemma A Williams 55. Strengthening primary care in Europe: How to increase the attractiveness of primary care for medical students and primary care physicians? Marieke Kroezen, Dheepa Rajan, Erica Richardson 56. Engaging the private sector in delivering health care and goods: governance lessons from the COVID-19 pandemic Anna Maresso, Ruth Waitzberg, Florian Tille, Yulia Litvinova, Gabriele Pastorino, Naomi Nathan, David Clarke The European Observatory has an independent programme of policy briefs and summaries which are available here: https://eurohealthobservatory.who.int/publications/policy-briefs The European Observatory on Health Systems and Policies is a partnership that supports and promotes evidence-based health policy-making through comprehensive and rigorous analysis of health systems in the European Region. It brings together a wide range of policy-makers, academics and practitioners to analyse trends in health reform, drawing on experience from across Europe to illuminate policy issues. The Observatory’s products are available on its website (https://eurohealthobservatory.who.int). World Health Organization Regional Office for Europe UN City, Marmorvej 51, DK-2100 Copenhagen Ø, Denmark E-mail: eurocontact@who.int Website: www.who.int/europe Print ISSN 1997-8065 Online ISSN 1997-8073 The Observatory is a partnership, hosted by the WHO Regional Office for Europe, which includes other international organizations (the European Commission); national and regional governments (Austria, Belgium, Finland, Ireland, Netherlands (Kingdom of the), Norway, Slovenia, Spain, Sweden, Switzerland, the United Kingdom and the Veneto Region of Italy (with Agenas)); other health system organizations (the French National Union of Health Insurance Funds (UNCAM), the Health Foundation); and academia (the London School of Economics and Political Science (LSE) and the London School of Hygiene & Tropical Medicine (LSHTM)). The Observatory has a secretariat in Brussels and it has hubs in London (at LSE and LSHTM) and at the Berlin University of Technology.