What do we actually mean by a European Health Union?

Eurohealth  —  Vol.26  |  No.3  |  2020 Perspectives on the European Health Union 30 What do we actually mean by a ‘European Health Union’? By: Anniek de Ruijter Associate Professor (EU) Health Law & Policy, University of Amsterdam, School of Law, the Netherlands. Almost a year after the global outbreak of the novel coronavirus in the beginning of 2020, we can now see the first signs of what the significant legislative and policy impact of this pandemic might be. In what may end up being one of the most notable outcomes, the European Commission has come up with a set of proposals  1 that would establish a ‘European Health Union’. At the same time, in a more bottom-up fashion, a manifesto  2 has come out on ‘a European Health Union’ as well. Importantly, as the German Chancellor signed off on the German Presidency of the Council of the European Union, Merkel clearly indicated her support for the creation of a European Health Union. 3 This sequence of events might suggest that it is clear what a European Health Union would entail, but it is not. What is meant by a ‘European Health Union’ is completely dependent on the criteria outlining what it will be in practice. So, what is a ‘European Health Union’? Or rather: what should it be? Even if the current plans are laudable – and politically steep – surely a European Health Union stretches beyond a narrow approach to dealing with health emergencies as proposed by the European Commission? Clearly, if only for efficiency, we need to strengthen public procurement for essential and emergency medical countermeasures; we also need improved coordination on health communication to European Union (EU) citizens during outbreaks; and perhaps even a strengthening of the executive power of the Health Security Committee – basically a stronger role for the EU in reacting to infectious disease threats/and other health threats that have a cross-border aspect. But a ‘European Health Union’ suggests more. The question is, how much more? Will a European Health Union mean that, after its establishment, access to high quality care will be the same in all countries? This seems unlikely as the current differences and inequalities between Member States are significant. At present, inequalities persist in a Union of states where the average life expectancy at birth is 80.6 years, yet drops to 74.7 years in Bulgaria and reaches as high as 82 and 83 years respectively in France and Spain. Additionally, out of pocket costs as a share of current health spending in the EU ranges from 9% in France to 47% in Bulgaria. 4 Can we call it a European Health Union when public inoculation programmes are exactly the same; mortality is calculated on the basis of a unified methodology; and the basket of available health care that is insured, is similar across Member States? Far from it, I would say. And there would not be many observers who would, at this point, normatively argue for such a level of EU integration in the field of health, nor would they empirically see this as feasible in the short or middle-long term. Although we should never be under-ambitious when it comes to health, we should always be skeptical, in my view, of simple positions on the European project that more integration is always better. However, when over the summer a diverse group of people in the EU health community started coming together, a lot of the conversation – that first focused on exactly the COVID-19 response measures and infectious disease management policies that the Commission has recently proposed – quickly broadened beyond the emergency frame. Indeed, the conversation expanded to broader ideas about how to “load” the concept of a European Health Union with substantial and constructive policy ideas and ideals that can all be found at www.europeanhealthunion.eu. Being part of the European health community used to give one a little time to think. That is to say, there were many important networks proposing policies or responding to them, but as an observer, one would be able to keep up with developments. This was due to two slowing factors: Firstly, the basic tenet of EU health policy was the unwillingness of Member States to let go of powers in the field and the lack of capacity at EU level (not of ambition). Secondly, where at Member State level public health and health care Eurohealth  —  Vol.26  |  No.3  |  2020 Perspectives on the European Health Union 31 policy is more integrated as a matter for policy and politics, in the EU there is more fragmentation in the field. We see a large body of regulatory policies and laws in the EU in the area of public health, but very limited possibility of ensuring access to health care in any sense that it would touch on a solidarity pact of Europeans to share the risks of disease and mortality. That is to say that the locus of power and actual ‘steering’ power in the EU on health is harder to identify, which can cause political inertia and delays. So, when a group of concerned people, academics, policy experts, representatives of patients and public health advocates interested in EU health policy and law started to come together online, we were all trying to make sense of the quick developments, and the immense political pressures, breakthroughs and set-backs we were seeing – all at the same time – in the field of EU health. While we first started to come together as an exercise of sense-making, this quickly moved to a call to action in a series of meetings in various groupings. Mostly this was fed by the concern for a move towards short-term, ad hoc and quick solutions. We came together in the context of the European Observatory on Health Systems and Policies, the Vilnius European Institute of Health and Sustainable Development, and as policy ideas became more developed, the preliminary meetings culminated in several meetings in the context of the European Health Forum Gastein 2020. Importantly, a large group of patients’ organisations and civil society that were already part of the Europe4Health initiative also joined, with a great Young Gasteiner Michele Calabro from the European Patients’ Forum (EPF) co-chairing with Zoltán Massay-Kosubek from the European Public Health Alliance (EPHA). What has come out of this process is the current Manifesto for a European Health Union, 2 that takes a much broader approach to where the EU can have a clear added value together with the Member States, outside of emergency reflexes and short- term solutions. As we move towards the Portuguese Presidency and toward the Conference for Europe, we bring this Manifesto to national parliaments, and national governments to take forward into a future EU. References 1   European Commission. A European Health Union: Tackling health  crises together - Coronavirus impact and response, Factsheet, 11  November 2020. Available at: https://ec.europa.eu/commission/ presscorner/detail/en/FS_20_2078 2   Manifesto for a European Health Union. Available at: https:// www.ehfg.org/documents/EHFG2020/partners/Manifesto- European-Health-Union/#page=1 3   Stone J. Angela Merkel calls for creation of European health  union. The Independent, 12 December 2020. Available at: https:// www.independent.co.uk/news/world/europe/angela-merkel- european-health-union-b1770039.html 4   Country Health Profiles of the European Commission: https:// ec.europa.eu/health/state/country_profiles_en; also see Eurostat,  Health in the European Union – facts and figures: https://ec.europa. eu/eurostat/statistics-explained/index.php/Health_in_the_ European_Union_%E2%80%93_facts_and_figures