Solidarity in health has never been so urgent or imperative—a European Health Union would be its ideal expression.
A European Health Union (EHU) appears to be emerging on the horizon. The notion was coined in the crucible of the pandemic last spring and catapaulted to the level of European Union policy by the president of the European Commission, Ursula von der Leyen, a few months later.
For years Eurobarometer surveys had shown public demand for ‘more Europe’ in health. In a 2019 survey, the five priorities for the EU in the years ahead, according to young people, were: protecting the environment and fighting climate change (67 per cent), improving education and training (56 per cent), fighting poverty and economic and social inequalities (56 per cent), boosting employment (49 per cent) and improving health and well-being (44 per cent). Only the crash induced by Covid-19 seems however to have awoken the political will to act.
As one public-health veteran put it bitterly at the European Health Forum Gastein 2020, ‘Health has been the Cinderella of public policymaking for a long time, nobody would listen, and we never got to go to the ball. Now we are the equivalent of the princess at the ball and everyone wants to dance with us.’ Unfortunately, there are still many reasons to doubt this ‘Cinderella’ story has a happy ending.
Health has never been accepted as a major EU policy area for solidarity and co-operation. It is not even itemised among the objectives identified in article 3 of the Treaty on European Union (TEU, consolidated version). It does appear in the Treaty on the Functioning of the European Union (TFEU): article 4 includes ‘common safety concerns in public health matters’ among competences shared with member states and article 168 is devoted to public health. But the EU role is largely restricted, as under article 2, to ‘action to support, coordinate or supplement the actions of Member States’.
Paradoxically, it is in the legal tradition to ground European regulations with important consequences for health in article 114 of the TFEU, linked to development of the single market (article 26)—as if good health were best framed as fuel for EU economies. Joint actions for health per se are confined to extreme cases: a regulation of the European Parliament and of the Council of the EU, approved in response to the pandemic last March, affirms that ‘the EU should intervene only in cases where a Member State is deemed no longer to be able to cope with a crisis alone and requires assistance’.
This inertia prevails against the allowance in article 5 of the TEU, on subsidiarity, for EU action in the arena of shared competences ‘by reason of the scale or effects of the proposed action’. It has been compounded historically by very limited explicit allocations to health in the EU budget: until recently, commitments to health never exceeded 1 per cent of the apportionments to the Common Agricultural Policy.
Asking for more
But does it matter to our citizens? Even if cautious about a high tax burden, European citizens are asking for more high-quality health services and are ready to pay more via health-insurance contributions or general taxation.
For decades, demand for health services has grown faster than the total economy, pushing up the share of gross domestic product devoted to healthcare. The most recent available Eurostat figures (2018) show that employment in health exceeds 9.9 million in the eurozone and is nearly twice as high as in agriculture, forestry, fishing, mining and quarrying and manufacture of basic metals—the dominant sectors at the start of European integration—combined (5.9 million).
The value of good health cannot however be defined only in monetary terms: it comprises one of the cultural backbones of our European civilisation, one of the mainstays of European wellbeing. And in a Europe much more interconnected since the Lisbon treaty, Europeans enjoy freedom of movement to live, work and travel—and use healthcare resources along the way.
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European solidarity in health has never been so urgent and imperative, in view of member states’ failures to manage the pandemics. But the need had been evident for years, confronting common challenges in vaccination, antimicrobial resistance and mobilisation of the scarce resources required for complex treatments while ensuring nobody is left behind in access to quality healthcare.
Common price negotiations are also needed for expensive medicines and technologies. And while all of us would like to benefit from medical innovations—personalised medicine or individualised care made possible by artificial intelligence and digital health applications—the competitiveness of Europe in research and development is increasingly lagging, associated with insufficient and inefficient collaborative funding.
Time to act
In the Manifesto for a European Health Union, we say the time to act is now, if not yesterday. Public health is among the ‘societal challenges’ to be addressed by the Conference on the Future of Europe. Agreement by European leaders to an EHU would be the perfect outcome of the 2020-21 political season and a highly welcome first step towards European health policies truly based on common European values.
Three scenarios are possible:
- utilising existing legal, financial and managerial instruments, upgrading functioning institutions and improving implementation of agreed policies;
- fine-tuning existing instruments, allied to secondary legislation and new institutions which can add value to European health;
- amendment of the TEU to provide for a European Health Union, giving the EU concrete competences in health policy while preserving subsidiarity.
In their December meeting, the Council of Health Ministers expressed strong support for the development of an EHU, on a trajectory of the first scenario with elements of the second. This is progress by comparison with the prevalent view of just a year ago, but it is crucial that progress does not stop after constructing these first building-blocks.
The best choice for Europeans would be to adopt the most ambitious, third scenario, providing citizens with the opportunity to reap all the benefits stemming from deeper co-operation in health. Let us amend paragraph 3 of article 3 of the TEU, which begins: ‘The Union shall establish an internal market.’ Let us add: ‘It shall promote universal health coverage by establishing a health union.’
Vytenis Povilas Andriukaitis is the special envoy of the World Health Organization for the European region. He was formerly European commissioner for health and food safety. Gediminas Cerniauskas is a partner and Birute Tumiene a senior expert with the European Institute for Health and Sustainable Development.