Zoltán Massay-Kosubek

Myth No.1 is that health is a national competence in the EU. This is not only a defensive and counterproductive statement but also legally and factually untrue: there are many policies, projects and initiatives, linking health relevant local, regional, national policies with European policies. The Economic Governance and the European Commission assessing national healthcare policies – which were published on 5th June 2019 – is a key example of that.

Debunking the ‘national competence’ myth as regards health

Your approach determines your willingness
: the way your frame your opinion on EU action in health policy indicates your intentions. I can see four reasons why being negative on EU action on health can backfire: ‘You are defensive’ – ‘It does not help’ – ‘It is legally incorrect’ – ‘The EU acts already a lot on health’

#1 ‘You are defensive’

If you start saying that the topic ‘health’ is not for the EU, you immediately lost your audience. If you talk about health in a European perspective, it is hard to convey any message if you say at the beginning basically that whatever I am saying afterwards is not relevant.

#2 ‘It does not help’

Being negative makes EU action more difficult to get accepted. We all now what policies are in place, what are the rules and what competences are in the Treaties. Therefore, it is clear what concrete actions can be done. Ultimately, it is your choice whether you would like to act within the framework of competences or you are looking for excuses not to act. Therefore, if you approach EU health policy focusing on what cannot be done, it is very likely that this is an argument for no action.

#3 ‘It is legally incorrect’

The key determinants of population health lie outside of the healthcare sector. This is – also – recognised by the Treaty on the Functioning of the European Union (TFEU) saying that ‘Health shall be included in all EU policies.’ This is a strong legal mandate for health in all policies and for impact assessment. As regards national healthcare, the treaties are also clear that this belongs to Member States. But this does not mean that the EU cannot interact at all! The Cross Border Healthcare Directive (Directive 2011/24/EU on patients’ rights in cross-border healthcare), the famous European Health Insurance card, the European Reference Network are tangible proofs that national healthcare systems do not exist in Vacuum but they are linked to each other. And there are also European connections which we cannot ignore.

#4 ‘The EU acts already a lot on health’

There is a long list of EU actions on health: tobacco, unhealthy food, air pollution limits, medicines, professional qualifications of doctors and nurses, health related research initiative, labeling, on-line advertisement, antimicrobial resistance just to name a few issues. EU actions include hard legislation, soft law (recommendations), standardisation, projects and other initiatives, often involving the civil society. By referring to the use of various competences in different policy fields it can be easily demonstrated what does the EU for health.

The example of Economic Governance

Since the economic crisis, the European Commission assesses national budgets with the aim to ensure fiscal consolidation, and indeed the Commission also covers national health budgets. By establishing that policy framework, the Member States gave right to the European Commission to assess their health budgets. What other link can be more evident to show the EU policy connection to Health?

As the current Director General for Health and Food Safety (DG Santé), Anne Bucher recently said:

“The European Semester cycle is part of the EU’s economic governance framework and helps EU countries to avoid excessive government debt, prevent macroeconomic imbalances, support structural reforms in various areas, including health, and promote jobs, social inclusion, growth and investment. The Commission’s proposals present the major areas for reform and give direction. But the Commission does not act on its own. The recommendations require the blessing from the Council in July of the same year, and Member States may decide to modify them during this process. The implementation of recommendations is monitored throughout the year and reported on in the Commission’s country reports in February/March the following year.”

Director-General for Health and Food Safety (DG SANTÉ) Anne Bucher : “I cannot imagine a cycle of economic, fiscal and social policy coordination without health policy, which supports longer and productive working lives and aims to make essential healthcare accessible for all.”

What should Member States do to improve healthcare?

The economic governance process do have direct implications on national healthcare systems. Reforms of the health systems are ongoing in several countries to ensure the accessibility of healthcare for all, while enhancing their cost effectiveness and sustainability. Member States should continue their efforts, giving priority to the careful design of comprehensive measures and to stepping up the adoption and implementation of health service delivery reforms. Further investment is often necessary to support and implement reforms in the health systems.

Just to illustrate, how direct and outspoken is the Commission on healthcare, see what did the Commission said about the Hungarian Health System in the draft Country Specific Recommendations addressed to Hungary:

Recital (12) says

‘Health outcomes lag behind most other EU countries, reflecting both unhealthy lifestyles and the limited effectiveness of healthcare provision. The prevalence of smoking, alcohol use disorder and obesity is one of the highest in the EU. Hungarians are among the most likely in the EU to suffer premature death due to bad air quality. The number of avoidable deaths is one of the highest in the EU partly due to inadequate screening and primary care management. There are significant socioeconomic disparities in access to quality care. Public spending on healthcare is below the EU average and citizens rely on out-of-pocket payments to access quality provision, which risks further widening the socio-economic health divide. The system remains strongly hospital-centred, with weaknesses in primary care, in particular early detection and prevention of chronic diseases. A sizeable shortage of healthcare staff thwarts access to care in poorer areas. ‘

About the European Semester process

Each spring, the Commission presents country-specific recommendations as part of the European Semester cycle that supports the coordination of economic, fiscal and social policies among the Member States in the EU. The 2019 Spring Package included a number of recommendations to encourage health reforms in the next 12 – 18 months

Next steps

Each EU member states, received tailored recommendations. It is expected that national Members implement them and include the them into their national budget plans and structural reforms. This also obliges the European Commission to include more health in its economic policy: barrow minded fiscal consolidation is not on option anymore without a broader, health supporting approach.

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