In November, the European Union for the first time staked a serious claim on the previously uncharted territory of national healthcare policy. Whether its intentions are advisory or prescriptive remains a moot point.
The opening of the third European Semester, the cycle of economic policy co-ordination launched in 2010 in response to the economic crisis, brought with it the first comprehensive analysis of the cost-effectiveness of health systems in member states. Last year saw the inclusion of healthcare factors in the annual growth survey, which begins the semester process, and the publishing of a thematic summary with country-specific recommendations for healthcare.
The milestone may seem bureaucratic, but it represents a step-change in how the EU regulates healthcare. “This is a competence grab in healthcare that is coming in via the economic governance work,” says Monika Kosinska of the European Public Health Alliance. “We think it’s the biggest power shift since the single market was set up.”
Two significant developments led to this policy watershed. First, the European Court of Justice ruled in 2006 that healthcare is a service that EU citizens must be given the right to receive. Four years later, the economic and financial crisis spurred the EU to launch mechanisms to control member states’ public spending.
“These two instruments demand a greater intervention of the European Commission in the management of the health systems,” says Paola Testori Coggi, director-general of health and consumer policy in the Commission. “Two years ago, it was impossible to discuss these issues with the member states. But now there is an acknowledgement the EU has a role to play.”
A raft of measures to assess national health systems followed, opening the way for the Commission to advise on or even criticise the healthcare policies of member states. On top of the European Semester cycle, new departures include a healthcare element in economic adjustment programmes, the directive on patients’ rights in cross-border care (see below), and a ‘reflection process’ on what a modern, responsive and sustainable health system should look like.
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This reflection process was requested by member states in 2011, and a final report will be delivered to them next October, with recommendations on cost-effective use of medicines, deployment of structural funds for health investments, effective monitoring of those investments, and better hospital management.
“The issue is not to reduce the spending on health, but to make it more efficient,” says Testori Coggi. Savings can be found by using more innovative devices, medicines and management processes. The Commission also wants to guard against the temptation to make cuts to health promotion and disease prevention (which account for just 3% of EU healthcare budgets), cuts which could deliver short-term savings but drive up spending in the long-term; and to reduce the unnecessary use of specialist and hospital care.
While the European Semester charges the Commission with ensuring that public spending on healthcare is judicious, the ECJ ruling obliges it to work for an even quality of healthcare throughout the Union. This is far from the case today. The gaps between the highest-performing member states and the lowest is enormous: life expectancy varies by up to 11.6 years, infant mortality is 50% higher in some states than others, and some have twice the level of chronic illness and twice as many people out of work because of sickness.
For the EU, this is virgin territory, and the coming year will do much to determine whether or not these exercises evolve into real EU-wide healthcare policy. But with the pressure to reduce public spending unrelenting, member states may cede some ground in these areas.
The main conclusions of the European Commission’s summary of health and health systems, December 2012
Spending on the health sector accounts for 10% of EU gross domestic product.
The Netherlands spends the most on healthcare as a percentage of GDP. Romania spends the least.
The Czech government contributes the least amount, as a percentage of GDP, to its health system of any member state.
Between 1995-2010, public healthcare spending as a percentage of GDP fell the most in Estonia and Hungary, and grew the most in Romania and the Netherlands.
Between 2010-20, public healthcare spending is projected to rise by the most in Malta, Denmark and Slovakia. It is projected to fall in Portugal, Greece and Luxembourg.
A changed EMA
The London-based European Medicines Agency, set up
by the EU in 1995 to co-ordinate approvals of pharmaceuticals by national regulatory bodies, has been through difficult times in recent years.
In early 2011, the agency found itself at the centre of accusations of mismanagement and close links with the pharmaceutical sector. The sudden resignation of then executive director Thomas Lonngren, who moved directly into the pharmaceutical sector, sparked charges of an unhealthily close relationship with the industry. The EMA’s ability to oversee the approval and monitoring of national agencies was called into question after the diabetes drug Mediator was found to be dangerous though it had been approved for the market.
The European Parliament withheld approval of the agency’s 2010 accounts because of concerns about financial mismanagement and questionable sub-contracting.
However, since Guido Rasi (pictured) took over the reins at the start of 2012, things seem to have calmed down. Rasi, who had previously reformed the Italian medicines agency AIFA, has set about making changes that have reassured many stakeholders on both transparency and competence. The reforms are still taking effect, but for now the agency looks to be on a more solid footing than in 2011.