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European Health Union – which direction to take?

As conferências Economia Viva, promovidas pelos alunos da Nova School of Business and Economics, tiveram este ano uma sessão dedicada à ideia de European Health Union. A sessão encontra-se aqui, com a participação de Miguel Guimarães, Ricardo Baptista Leite e Adalberto Campos Fernandes.

E a sistematização escrita da minha participação:

The starting point

Countries in the EU have very different health systems.

Health systems differ in the way they are funded (through taxes/public sector vs through regulated private health insurance).

Health systems differ in their way to deliver health care (public sector mainly vs private sector mainly).

Health systems differ in their organisation (regional systems, integrated, or not, of insurance with provision)

Countries differ in the relative valuation of main objectives (say, willingness to pay more for quicker access to innovation, valuing freedom of choice by patients per se, etc.)

The road ahead

Health systems face common challenges.

Public goods (in economic sense) and externalities exist: it makes sense to have only one European Medicines Agency and only one European Centre for Disease Control and Prevention.

It makes sense for countries to join forces to do procurement of products and services

European health systems also share values regarding inequities (say, it is probably acceptable to everyone that access to cancer treatment should be independent of the country where the person was born).

We may find convergence on overall goals of health systems, even if the “instruments” to get there (the actual design of the health system) may differ from country to country.

To move forward on the idea of a European Health Union, we should focus on:

  1. solidarity on health protection but not impose common rules for responsibility (which is dealt nationally, according to the preferences of each society).
  2. sharing information, sharing knowledge, sharing standards (increasingly important in a fast-moving digital health space at European level), sharing best practices, etc.
  3. sharing EU-wide initiatives where national drive has been largely insufficient (comes to mind public health actions on implementation of tobacco legislation, but also likely to be relevant to leverage on EU “shoulders” for actions related to alcohol ad nutrition, addressing obesity trends).

Barriers exist, some of which

  1. are likely to come from domestic politicians (health is also a major issue in domestic politics in several, if not all, countries; internal politics will find difficult to render part of it to the EU level);
  2. are likely to come from pressures that will take one country against another (say, international movements of health care professionals, in an international market with overall excess demand);
  3. are likely to come from technical details in how international payment of providers may be done;
  4. are likely to come from European politicians and their perceptions and goals. The main issue is not one of changing EU competencies in health (care or financing). It is how to extend or create instruments at the EU level that national health systems can use. The cross border health care directive and the health technology assessment regulation (under discussion) do not meet the role of being instruments, go too much on the direction of EC conducting health policy and his created adverse reactions.

What can be done:

Thinking in terms of instruments that can be used also allows for a flexible participation. It does not need to build EU-wide consensus for a country to use instruments.

One example of such an instrument is the creation of a resilience test for EU health care systems, with a common methodology that allows countries to learn from the application of the resilience test (from their own testing and from testing done by others).

Another example is the European Health Data Space, where obvious gains from coordination across countries exist. 

A third example is the (much discussed) initiative of joint acquisition of COVID-19 vaccines. While this process has made the headlines for several weeks due, mainly, to issues of securing the contracted amounts of vaccines from AstraZeneca, it is important to look at the “dog that didn’t bark”: EU countries did not fight each other about access to the vaccine. So far, no EU country blamed another EU country. No accusations of one EU country “stealing” vaccines from the others, even if tensions seem to grow. Failures in the vaccination process have been put on the account of the other EU countries’ actions. This is a major accomplishment of the initiative. It also showed the importance of treating contracts as something that rules a transaction between parties and not as a regulation or a directive. Setting contracts and enforcing them requires a different set of skills than enacting regulations and establishing international treaties. The EC (and the EU) are just starting to learn this (the hard way, unfortunately).

The EC plans will work?

It will depend on the path taken by the EC. Take two points from what was announced in November:

  1. reinforce surveillance, under coordinated action within the EU. It is clear the existence of a positive effect from one country doing it upon the other countries. There is a gain from sharing the cost of the effort of building the tools for it. It is likely to succeed, and more so if it concentrates in creating opportunities for improvement that countries may take voluntarily.
  2. strengthen preparedness, that is, develop plans for countries that will be audited and stress tested by the EC (or by EU agencies). It will likely meet opposition as a one-size-fits-all approach (or close to it), even if plans are different. I guess that the idea of plans and audits centrally determined will be resisted by health systems.

(The website of the European Health Union also refers to the pharmaceutical strategy and to the Europe’s Beating Cancer Plan, both could be a good topic for future discussion on what precise role they will have to help, or not, build a European Health Union).

As final remarks, we will certainly move in the direction of a European Health Union. It is going to be, I believe, a rocky road. It will not deliver a homogeneous European Health System. It is simply not feasible to build a single health system in Europe, due to existing differences that reflect different preferences of societies.

To live with the diversity of health systems means that a European Health Union should focus on those aspects that have one or more of the following characteristics:

  1. be an economic public good, like the activity of the ECDC
  2. have important positive externalities, like the European Digital Health Space
  3. interests of national health systems are aligned, like the joint procurement of products and services
  4. promotes share values across countries, like solidarity and equity in access to health care