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1 Introduction
The financial and sovereign debt crisis has had implications not only on national health system policy but has also changed the way health system aspects are discussed at European Union (EU) level. At national level, the crisis has predominantly led to the adoption of retrenchment measures in health policy, which have been well documented in terms of their public health and health care system effects (European Hospital and Healthcare Federation, 2011, 2012; Garcia Rada Reference Garcia Rada2011a, Reference Garcia Rada2011b; Kentikelenis et al., Reference Kentikelenis, Karanikolos, Papanicolas, Basu, McKee and Stuckler2011; Barros, Reference Barros2012; de Belvis et al., Reference de Belvis, Ferre, Specchia, Valerio, Fattore and Ricciardi2012; European Federation of Nurses Associations, 2012; Mladovsky et al., Reference Mladovsky, Srivastava, Cylus, Karanikolos, Evetovits, Thomson and McKee2012). At EU level, health-system reforms towards austerity are additionally stimulated by economic adjustment programmes in some bailout countries (Fahy, Reference Fahy2012) and potentially by the stricter enforcement of the Stability and Growth Pact (Chalmers, Reference Chalmers2012). Meanwhile, the initiation of discussions in support of health systems has included actions to back reforms and innovations inter alia in chronic disease treatment, hospital organisation (Council of the European Union, 2010b, 2011a), health investments or integrated care arrangements (Steering Group on the European Innovation Partnership on Active and Healthy Ageing, 2011; European Commission, 2012a). In addition, existing EU policies on health professional and patient mobility also have the potential to alleviate negative consequences from the crisis. Since both, new and existing EU health policies, have not been appraised with regard to their implications for health systems, this paper explores the positive or negative effects these policies have in light of the crisis.
Our analysis reveals that, first, the EU is increasingly and proactively discussing aspects of health care policies (Fahy, Reference Fahy2012). On the basis of the Treaty, public health policies have been the centre of the EU policy agenda and health systems were addressed rather reactively when influenced by spill-over effects from other policy domains. As health systems are facing increased pressures because of the crisis, more targets and objectives related to health systems have been on the EU agenda to add to national initiatives. Second, our analysis reveals that established EU provisions on patient and health professional mobility include chances to alleviate the negative effects of the crisis while simultaneously aggravating problems probably further. Individual patients and health professionals have the possibility to ‘escape’ deteriorating health services and unemployment, respectively, by choosing the cross-border route. However, at the system level, this can exacerbate existing problems of securing financial viability and stable service provision by the loss of financial and human resources. Third, health systems are progressively regarded as loci for achieving economic growth. Whereas health goals have been seen as objectives of the Union in their own right or as prerequisites for economic growth, the current tendency is to link them more closely to the EU's growth narrative (Borg, Reference Borg2012). Fourth, member states (MS) have announced to cooperate and exchange in a more enduring and tighter way on health systems than before.
To illustrate these findings, we appraise five areas of EU policies that comprise a health system dimension and explore their potential benefits or drawbacks in light of the crisis. The patchwork character of EU health policyFootnote 1 (Hervey and Vanhercke, Reference Hervey and Vanhercke2010) implies that discussions are spread over different policy fields involving a diverse set of actors, instruments and applicable ‘ground rules’ (Greer, Reference Greer2008). The five policies under scrutiny include (1) patient and health professional mobility, (2) the European Innovation Partnership on Active and Healthy Ageing, (3) the 3rd Public Health Action Programme, (4) Structural Funds (SF) (5) and the reflection processes in the area of health. For each EU policy domain, the goal or the potential to contribute to the sustainability and efficient operation of national health systems has been reported. Moreover, the five policies address basic arrangements of European health systems as they are likely to affect supply and demand of services and stimulate broader innovations in health care services rather than looking into narrow policy issues. To analyse these policy areas, we draw on a review of EU policy documents including strategic policy documents, minutes of EU-level meetings, soft law documents and law proposals addressing the policy design in the next financial framework of 2014–2020. In addition, from a review of the scientific literature, further insights into the EU health policy debates are gained.
Our findings raise additional questions to the broader ‘contradictions and challenges’ of subsidiarity, the asymmetry of economic and social responsibilities and social cohesion that are inherent in EU health policy (Mossialos et al., Reference Mossialos, Permanand, Baeten and Hervey2010), which we will address in the ‘Discussion’ section.
2 EU health policy in light of the crisis
The financial crisis has changed the degree and scope of pre-existing health systems challenges. This analysis discusses to what extent EU health policies, and the manner how national reform efforts are supposed to be supported, are suited to address the challenges for health systems the crisis has exacerbated.
2.1 Professional and patient mobilityFootnote 2
The potential influence of the financial crisis on patient and professional mobility demonstrates that the existing balance between free movement and the protection of health system goals can be distorted. The countries that are hit mostly by the crisis are potentially those that are suffering the most from the loss of health professional and resources. Increasing economic disparities are likely to increase health disparities propelled by incentives for professional and patient mobility. Currently, the opportunities of intensified cooperation between MS on cross-border care and health workforce planning seem to be insufficient to alleviate additional disparities between countries.
2.1.1 Professional mobility
Since the 1970s, professional mobility of the health workforce has been subject to secondary EU legislation. However, in the last decade, health workforce questions have entered the European health policy agenda more prominently (European Commission, 2008, 2012c; Council of the European Union, 2010a) because of prognoses of increased professional mobility in an enlarged EU 27 and due to labour shortages in light of the demographic change. Easier access to other labour markets in an enlarged Europe with increased wage differentials has raised concerns of a brain drain (Bala and Lesniak, Reference Bala and Lesniak2005; Starkiene et al., Reference Starkiene, Smigelskas, Padaiga and Reamy2005). In addition, along with demographic change, the increasing demand for health professionals and the reduction of the number of people of working age, is leading to general health workforce shortages. Internal estimations by the European Commission expect a total shortage of 1 million health professionals by the year 2020. Professional labour mobility can be a partial solution for countries with an overall inflow of professionals but aggravate the problem in countries with a net loss of professionals.
The actual level of health workforce migration is diverse in the EU. All MS recognise outflows of health professionals, whereas the level of inflow is considerable higher in many old MS compared with new MS. Looking at the pattern of workforce migration, western European countries like Belgium, Austria, France, Germany recruit their foreign professionals mainly from EU and European Economic Area countries, whereas the majority of foreign professionals in the United Kingdom is from outside Europe and in Slovenia from Balkan countries, respectively. Lastly, health professional mobility is particularly pronounced in border regions such as at the German–Austrian border, around the Baltic Sea or between the Benelux countries and France (Maier et al., Reference Maier, Glinos, Wismar, Bremner, Dussalt and Figueras2011).
The current financial crisis has the potential to increase professional mobility among health workers in Europe particularly because a number of countries have introduced anti-crisis austerity measures with regard to health professionals namely dismissals, recruitment freezes, wage freezes or wage cuts (Houston et al., Reference Houston, Day, de Lago and Zarocostas2011; European Federation of Nurses Associations, 2012; Mladovsky et al., Reference Mladovsky, Srivastava, Cylus, Karanikolos, Evetovits, Thomson and McKee2012). On the contrary, health systems and their professionals in some countries are not affected or have even increased resources. Thus, since there is no uniform development, it is likely that wage differentials will widen throughout Europe (Mladovsky et al., Reference Mladovsky, Srivastava, Cylus, Karanikolos, Evetovits, Thomson and McKee2012).
In addition, dismissed health professionals will seek job opportunities in countries other than their home country. Reports from Estonia, Latvia and Romania already suggest that increased emigration of health professionals is likely (European Hospital and Healthcare Federation, 2011, 2012). An increase in mobility of highly qualified job seekers from Mediterranean countries to Germany has also been reported (Bundesagentur für Arbeit, 2012). In this regard, the revision of the Directive 2005/35/EC strives to ease professional mobility in Europe by the introduction inter alia of a professional card, common training frameworks or easier access to information on how to recognise qualifications in another MS. However, to balance free movement rights and patient safety concerns the current proposal allows now for (systematic) language testing for health professionalsFootnote 3 (European Commission, 2011a).
To meet language needs in general multilingualism is advocated by the European Commission as a personal escape route out of the crisis and indications exits that more and more Southern Europeans are learning for example German. Therefore, those countries most affected by the crisis may suffer from an excess outflow of their health workforce. Hereby, future health workforce shortages are likely to intensify.
In light of the strive to facilitate professional mobility, health workforce planning need to be reappraised. First, the WHO Global Code of Practice on the International Recruitment of Health personnel, a voluntary code for ethical recruitment, is only partly applicable, since the free movement provisions of the EU's internal market prevail (Glinos, Reference Glinos2012). Second, proposals for extending the use of European Social Funds (ESF) resources for training and education of health professionals in the forthcoming financial framework could help partly to alleviate the effects of a brain drain. Third, the Commission's Joint Action on Health Workforce Planning and Forecasting to secure a sufficient number of health professionals in the future should incorporate crisis-related developments in human resources. Professional mobility and health workforce infrastructures are very likely to be affected by resource cuts caused by the crisis (Aluttis et al., Reference Aluttis, Brand, Michelsen, Costongs, Chiotan, Van den Broucke, Otok, Jelfs, Baer, Barnhoorn, Levin-Zamir and Rechel2013). An EU wide observatory on workforce planning providing sustainable coordination and support among MS only has proposal status so far (Matrix Insight, Reference Matrix2012). In light of the right to move freely in the EU as a worker and the strong incentives present in some countries currently to use these rights, it can be questioned if the voluntary code for ethical recruitment, extended ESF funding and MS cooperation can sufficiently prevent the negative effects of anticipated, additional professional outflow.
2.1.2 Patient mobility
ECJ’ s case lawFootnote 4 on patient mobility and cross-border care has established that health care systems are subject to the free movement provisions of the EU's internal market. At the same time, social protection goals have been accounted for by allowing to limit the right for treatment abroad for hospital treatment and limiting reimbursement to the level of their home country's social security tariffs. In addition, reimbursement of treatment abroad is only granted for health care services that are included in the domestic benefit package. This has recently been codified in the Patient Rights Directive (PRD; European Parliament and Council of the European Union, 2011). The scope and linked costs of patient mobility have been estimated so far to be small, only <1% of the overall health care resources are spent on cross-border care (Rosenmöller et al., Reference Rosenmöller, McKee, Baeten and Glinos2006). The crisis incorporates some drivers for increased patient mobility that can have detrimental as well as positive effects on health systems.
The character and scope of patient mobility may alter due to the financial crisis when policy responses in health care include increases of user charges, prolonging of waiting times and lowering the density of secondary care facilities (Mladovsky et al., Reference Mladovsky, Srivastava, Cylus, Karanikolos, Evetovits, Thomson and McKee2012). As such, cuts in the benefit package of reimbursed health services, increased cost-sharing provisions and increasing geographical remoteness to health care and decreasing number of care providers have been identified as barriers to the access of health services within a country. At the same time these measures are described as motives for patients to consider health services in other countries (Busse et al., Reference Busse, Van Ginneken and Wörz2011). Since policy measures of retrenchment are not uniform across Europe (European Hospital and Healthcare Federation, 2011; Mladovsky et al., Reference Mladovsky, Srivastava, Cylus, Karanikolos, Evetovits, Thomson and McKee2012), they create pressure to seek care across borders. The potential negative health system effects are threefold.Footnote 5 First, by seeking (additional) care abroad domestic policy measures to save costs by restricting the supply of services (Glinos et al., Reference Glinos, Baeten and Boffin2006) or by the rationing of care are undermined. Second, patient mobility can incur additional costs for the home country because the availability of services or extent of care per patient increases, which would not be the case in a pure internal situation (Glinos and Baeten, Reference Glinos and Baeten2006; Baeten, Reference Baeten2011). Third, the treatment of patients abroad is accompanied by an outflow of resources for health systems. Hence, a country's desire to invest in its own health system is further limited at a time when investment for restructuring is more urgent than before (Jesse and Kruuda, Reference Jesse and Kruuda2006; Baeten, Reference Baeten2011). Thus, there is a potential that the facilitation of patient mobility puts additional pressure on those health systems in Europe that are comparatively severely hit by the crisis.
However, so far the overall numbers of patients seeking care abroad is low and only a small share of overall health care resources is spent on cross-border care. Next to that, the PRD has increased MS’ control over cross-border care they reimburse. The PRD extends the prior authorisation rule from ‘hospital treatment’ to treatment involving ‘highly specialised and cost-intensive medical infrastructure or medical equipment’ [Article 8 (2)] on the basis of planning and cost reasons, which have been argued for the hospitals setting accordingly. Moreover, additional reasons for prior authorisation have been allowed for in Article 8 and it is clearly stated now in Article 7 that cross-border care is restricted to the basic package determined by MS (European Parliament and Council of the European Union, 2011; Hatzopoulos and Hervey, Reference Hatzopoulos and Hervey2013).
On the contrary, the PRD and cross-border care arrangements could help towards a more efficient and cost-effective organisation of health care. Baeten (Reference Baeten2011) discerns in this regard three ways how ‘steered’ patient mobility can be financially beneficial. First, tasks and infrastructure can be shared across borders. Second, co-financing of highly specialised treatment facilities can be organised across borders (Glinos and Baeten, Reference Glinos and Baeten2006). Third, ‘outsourcing’ of treatments to other countries is an option when the low number of patients to be treated does not justify a country investing own resources in the build-up of professional skills and care infrastructures (Azzopardi Muscat et al., Reference Azzopardi Muscat, Grech, Cachia and Xuereb2006; Baeten, Reference Baeten2011). However, Baeten describes how cross-border arrangements can involve expensive administrative costs, which make them less attractive. In addition, the setting up of cross-border arrangements might need some additional start-up investments, which can be hard to realise when resources are scare.
Additionally and beyond the direct facilitation of patient mobility, the PRD foresees various types of national cooperation that offer solutions for more general questions of health care re-organisation in light of the demographic change and financial crisis. Intensified MS cooperation in areas such as rare diseases, eHealth and health technology assessment (HTA) can help to provide health care more efficiently and cost-effective. The establishment of a European Reference Networks on rare diseases would allow exploiting economies of scale for diseases of which the prevalence is low by organising the training of specialists and the supply of specific infrastructure on a European scale rather than nationally. The introduction of eHealth applications like telemedicine, data management and tele-monitoring in health care on a wider scale is expected to deliver care more cost-efficient and more convenient care for patients. Lastly, the incorporation of HTA findings in health policy decision making supports the goals of safe, effective and efficient health (care) interventions and organisation.
In sum, the crisis involves incentives for increased patient mobility which in turn could have potentially detrimental effects at the health systems level. Faced with a potential outflow of resources, current provisions protect health system goals but can certainly not deprive patients of the right to seek health care abroad. On the contrary, it remains unclear whether or not benefits through economies of scale and additional national cooperation can be realised.
2.2 European Innovation Partnership on Active and Healthy Ageing
Since the European Innovation Partnership on Active and Healthy Ageing (the partnership) is part of the Europe 2020s flagship initiative Innovation Union, it ties health priorities – a two years increase in healthy life years – very much with economic priorities of growth and support to European enterprises. While the initiative should be welcomed to address structural challenges linked to demographic change, a number of flaws and difficulties are worth noting. First, the partnership is criticised for its narrow (technological) approach to achieve health system goals and an increase in healthy life years (Ahtonen, Reference Ahtonen2012), which corroborates the economic objective of the partnership. Second, the lack of dedicated resources within the partnership when budgets are tight is problematic. Third, establishing the link with growth and business solutions will be hard to realise in health care systems in a period of austerity. This could even lead to the uneven use of funds and increase differences between systems even further.
As stated in the implementation plan, a ‘triple win’ is sought by the partnership including improved population health, a reduced burden on health care systems and increased growth and market potential for European enterprises. The partnership concentrates on three thematic pillars: (1) prevention, screening and early diagnosis, (2) care and cure and (3) active ageing and independent living. Health system issues are addressed in all pillars but are central in Pillar 2 where innovative approaches to professionals’ training, tackling multi-morbidity and integrated care arrangements are supported (European Commission, 2012d). However, the proposed areas for actions are regarded as less (cost-) efficient than a comprehensive focus on health promotion. The EU is encouraged to consider regulatory and policy interventions across various sectors to promote healthy lifestyle changes on diet, physical activity and smoking. For a more inclusive approach adaptations are envisaged to among others the Common Agricultural Policy, the Horizon 2020 proposal, educational, social and employment policies (Ahtonen, Reference Ahtonen2012).
However, since the partnership aims to lend support to health industries as innovative approaches should be converted to marketable business solutions (European Commission, 2012d) the promotion of a healthy lifestyle and adequate care for the frail is sought by financing focussed (technological) innovations (Ahtonen, Reference Ahtonen2012). In addition, the emphasis on marketable business solutions raises the question of who will pay for these innovations once on the market and if they are likely to make the provision of care less or more costly. Moreover, there is a risk that the health systems and health industries hit hard by the crisis may not be able to demonstrate the growth and business dimension to profit from the partnership.
The partnership has no discrete funding but aims at synergy effects by inviting other existing funding schemes to take on the proposed targets of the partnership. The European Commission wants to ensure that the priorities of the partnership will be taken into consideration including the allocation of budgets in the other EU funding schemes such as the Public Health Action Programme, Structural Funds, Framework Programme 7/Horizon 2020 or INTERREG (European Commission, 2012e). It involves the risk that resources are shifted from pre-existing and agreed funding priorities in the schemes, which are still relevant. Additionally, the Commission seeks to support marketable business solutions and incentives for private firms to invest by adapting relevant EU legislation such as EU data protection, public procurement, research funding and EU standardisation provisions (European Commission, 2012d). It remains to be seen how the overall ambitious goal of two healthy life years gained by 2020 will be reached with a limited scope for actions and without dedicated funding resources. This is especially so in times of economic decline when financial resources are scarce.
2.3 Structural funds
Current developments in EU SF suggest that by streamlining the SF objectives with the growth targets of the Europe 2020 agenda, health targets are subsumed under economic goals. Moreover, while efforts to increase the effectiveness of SF investments in health by conditionalities are incorporated, it remains unclear if SF resources can alleviate regional differences when overall national austerity measures run counter to them.
EU SF aim at regional development in Europe by stimulating economic growth and social cohesion in and among European regions. Thus, welfare is re-distributed between economically stronger and weaker regions in Europe. In the past, EU enlargement has widened not only economic inequities but also health inequities throughout the EU. It has led to the inclusion of health targets in the SF policy in the current financial framework 2007–2013 in which ∼5 billion euros have been dedicated for direct health investment. So far, the resources of the European Regional Development Fund have been predominantly used for health infrastructure investment to (re)construct health care services. Projects have focused especially on hospitals and eHealth applications. In addition, ESFs’ resources can be used to train health care personnel and create healthy workplaces (Watson, Reference Watson2009). The financial crisis is likely now to accelerate regional differences in economic performance as countries have been affected to varying degrees. This makes the attainment of regional cohesion harder, but demonstrates at the same time that the goals of the SF are even more relevant than before.
In light of the crisis, the proposal for a Regulation regulating the use of SF for the next programming period 2014–2020 has defined the objective in accordance with the overall Europe 2020 strategy. This implies that SF resources used for health are not ring-fenced anymore, but need to be justified in support of Europe 2020s growth narrative. In addition, the proposal foresees the introduction and enforcement of conditionalities to ensure higher effectiveness of investments for regional growth and social cohesion. This affects the pursuit of health targets within SF, too. Starting from 2014, conditionalities have to be fulfilled by MS when submitting their Operational Programmes specifying the use of SF resources in their country. These conditionalities link envisaged actions funded by the SF with domestic regulatory provision that need to be in place. With regard to the pursuit of health goals, these include, first, in case of eHealth objectives, outcome targets for eHealth in the domestic innovation strategies. Second, for the national Operational Programmes addressing active and healthy ageing challenges, actions need to be drafted according to the EU Employment guidelines (Council of the European Union, 2010c). Third, for other health objectives, the existence of a domestic strategy for health to guarantee quality and sustainability of health services is required including action to promote efficiency and the use of, among other things, technological innovations (European Commission, 2012f).
Proposed changes to the SF Regulation demonstrate a closer link between growth goals and health. Furthermore, the conditionalities make sure that SF funding is embedded in a supportive environment of existing national and EU policies. The envisaged consistency is sought to ensure higher overall effectiveness of investments. Hence, health policy objectives such as health equity are more closely coupled with the overall goal of promoting regional growth. Despite ongoing and future EU investments in health infrastructure, it is questionable if national austerity measures such as the closing of care facilities, dismissal of personnel or the introduction of co-payments are limiting access to health care overall and increasing health inequities further.
2.4 3rd Public Health Action Programme
The proposal for the 3rd Public Health Action Programme for the period 2014–2020 addresses health systems in light of the financial crisis. In the explanatory memorandum of the European Commission attached to the legislative proposal, first, the European Commission argues that the crisis has made questions of sustainability and cost-effectiveness more pressing. Moreover, it is stated that ensuring accessibility and quality of care is a delicate task when resources are limited. Therefore, in the proposal for the 3rd Action Programme two entire objectives are dedicated towards health care system issues: one aiming at innovations to secure sustainability and the second to promote access to and safety of health care (European Commission, 2011b). It implies a considerable shift towards health care-related objectives, since health care has not been a primary objective but was only moderately addressed in the 1st and the 2nd Action Programme (European Parliament and Council of the European Union, 2002, 2007).
Second, the proposal very much connects health targets and economic growth ‘to a greater extent than the previous programmes’ (European Commission, 2011b: 2). The health sector is regarded as a ‘driver for growth’ due to its potential for (technical) innovations such as eHealth solutions. Within its programme, the European Commission intends to encourage financial sustainability by setting incentives for ‘the most innovative and valuable products and services, which at the same time offer the best market potential and cost savings in the longer term’ (p. 4). Although the notion of a healthy population as a prerequisite for economic growth is mentioned, it is not the leading rationale in the explanatory memorandum. Comparing the framing of the connection between health and economic growth to the one in the EU Health Strategy, it reveals a shift from health predominantly regarded as prerequisite for growth towards the health sector as a contributor to economic growth (Borg, Reference Borg2012).
The Action Programme is supposed to influence discourses or political agenda and thereby to influence potentially health care practice and the organisation of national health care systems (Hervey and Vanhercke, Reference Hervey and Vanhercke2010). The actions financially supported by the Action Programmes include the cooperation among MS’ health systems and a greater coordination and knowledge exchange between national health policy makers at the European level. It involves the supply of comparative health data, benchmarking and the facilitation of policy learning using best practice exchange and co-ordination efforts.Footnote 6 However, evaluations of the EU Health Strategy and EU Action Programmes have reported little impact on national practices so far (European Court of Auditors, 2009; Public Health Evaluation and Impact Assessment Consortium, 2011a, 2011b). Given the comparable small budget of the programmes, the unfavourable, overall economic situation and competing national and European policy initiatives for retrenchment, its potential influence can be questioned even more.
Nevertheless, the proposal for the 3rd Action Programme and the shift towards health system objectives should be welcomed, since the health care reforms have become more difficult because of the crisis and are of major concern to national health decision makers. The Public Health Action Programme can certainly stimulate greater cooperation and coordination on health system-related issues among MS. At the same time, the framing of health system objectives are more closely tied to economic goals. It remains to be seen if the Action Programme can influence national discourses and if so, can set the right incentives for health system reform.
2.5 Reflection processes
The reflection processes reveal the intention of MS to cooperate and exchange knowledge on health system matters more than before. Compared with the Commission's growth approach to health system, issues of cost-effectiveness, questions of management and investment decisions are central topics of national concerns in light of the crisis. Although the reflection process is intended mainly for MS cooperation, there is involvement by the European Commission as well, as it delivers input to meetings and chairs subgroups of the reflections process or organises the expert panel on health investments.
Both the Council Conclusions on ‘Innovative approaches for chronic diseases in public health and health care systems’ and ‘Towards modern, responsive and sustainable health systems’ (Council of the European Union, 2010b, 2011a) called for the introduction of reflection processes to identify responses to the challenges of chronic diseases and of sustainable finances of health systems. The reflection process is a more durable engagement with these themes under the auspices of an existing EU forum for national exchange, the Working Party Public Health at Senior Level. Reports indicating the areas of MS’ interest and recommendations for further actions are the envisioned output of these activities.
On the basis of the Council Conclusions, the reflection process on innovative approaches for chronic diseases aims to give recommendations for better chronic disease management including health promotion and prevention, health care and research (Council of the European Union, 2010b). The concern about an ageing European population and the cost-effectiveness of chronic disease treatment has increased since the start of the crisis. It is identified by the Working party as one of the topics to be addressed in the reflection process (Council of the European Union, 2011b). A first output of the reflection process will be a report summarising the key areas of concern regarded by MS and suggesting further activities within the reflection process and beyond. The themes have been narrowed towards innovative approaches in health promotion and disease prevention and chronic disease management and good practice exchange. An initial questionnaire among all MS based on a consultation paper has helped to identify the areas of most interest (Council of the European Union, 2012a). An interim report has been discussed in September 2012 and MS supported the report's suggestions for the establishment of a Joint Action on chronic diseases targeting (1) mechanisms to validate good practice, (2) a case study on diabetes care and (3) actions on care pathways for multi-morbid patients. Second, MS were in favour of a mapping exercise on patient empowerment in chronic disease management (Council of the European Union, 2012b). Both actions, the Joint Action and the mapping exercise, have been included in the Work Programme 2013 of the second Action Programme on Public Health (European Commission, 2012b).
The goal of the reflection process on modern, responsive and sustainable health systems is to support the re-organisation of health services towards more effective systems and to use limited budgets efficiently (Council of the European Union, 2011a). The Council Conclusions explicitly refer to the combined problem of increased costs linked to the demographic change and reduced available budgets connected to the crisis. Moreover, the Council Conclusions recognise that the crisis has changed the ‘scale and urgency’ to safeguard health system objectives and in case they remain unaddressed, can alter the economic and social conditions in the EU (Council of the European Union, 2011a). The reflection process has been organised by dividing five different sub-groups working on (1) the presentation of health in the National Reform Programmes led by the Commission, (2) effective health investments and financing including the use of SF, (3) the cost-effective use of medicines and (4) integrated care models and better hospital management and (5) measuring and monitoring the effectiveness of health investments. Subgroups 2 to 5 are led by MS with the Commission having the role of a coordinator guiding the process of the subgroup. Each subgroup plans to submit a report by the end of 2013 including recommendations for further actions (Council of the European Union, 2011c, 2012b).
In addition to the initiation of the reflection process, the Council Conclusions of 2011 state that the European Commission should support the reflection process by offering tools such as health system performance assessment, new ways of European level funding for health systems and expert advice on health investments (Council of the European Union, 2011a). Providing expert advice on health investments has resulted already in a decision to set up a multi-sectoral and independent expert panel on effective ways of investing in health (European Commission, 2012a). The expert panel is to provide expertise and compile knowledge on how to invest most effectively in health systems. The field of expertise covers comprehensively a broad range of issues in health care and public health and organisational aspects of health systems (see Annex 1 of the Decision). The panel is organised by the Commission and is expected to run until 2015 with the possibility of being extended. It is emphasised that advice is non-binding and provided only upon request of MS (European Commission, 2012a). Nevertheless, since several MS have resorted to health system reforms because of reduced financial resources, an expert panel will be available to support national health reform initiatives by giving MS access to 12 European experts. To some extent, the expert panel and the other plans of action demonstrate that MS are willing to allow for more involvement of the European Commission in facilitating cooperative actions and policy learning on health systems at the EU level.
As these Council Conclusions are a declaration of intent by national ministers of health, they reflect a greater willingness of MS to engage in a more structured and continuing exchange at the EU level on specific health care-related topics. Compared with earlier EU Council Conclusions, the introduction of a reflection process is intended to enable strategic discussions among MS on these important issues and alleviate the problem of changing agendas because of rotating Council presidencies. The reflection processes offer possibilities for mutual learning among MS and for taking joint efforts on the problems health systems face during the crisis. However, due to the need to factor in diverging national priorities, the production of the reports seems delayed. Moreover, in what way the recommendations will be taken up or lead to concrete actions remains unclear so far.
3 Discussion
Previous studies on the effects of the financial crisis and the role of the EU in health policy have focused on the negative impact on both health and health systems of retrenchment responses (e.g. Kentikelenis et al., Reference Kentikelenis, Karanikolos, Papanicolas, Basu, McKee and Stuckler2011; Mladovsky et al., Reference Mladovsky, Srivastava, Cylus, Karanikolos, Evetovits, Thomson and McKee2012) and the narrowed policy leeway for national decision makers because of tighter EU fiscal governance (Chalmers, Reference Chalmers2012; Fahy, Reference Fahy2012). These contributions have largely focused on the national level and have been mostly inattentive to the potential of EU health policies in light of the crisis. Using a review of EU policy documents and scientific literature, we identified a number of EU health policies potentially supportive of national health systems. An assessment of these EU policies has been performed incorporating current developments connected to the financial crisis.
The concentration on health system objectives at the EU level has increased during the crisis. The European Commission has adopted several initiatives on questions of health system organisation. Further, MS have expressed their intention to collaborate more intensively than before on health systems on the EU level. Emerging health policy initiatives contain proposals for more stable cooperation structures on chronic disease management and health investments to exploit benefits from mutual learning and information exchange on pressing health system issues. Moreover, established network and joint action structures are also used increasingly to collaborate in this area. The framing of health system goals especially in the Commission's financing instruments shows a stronger emphasis and closer link between health goals and economic targets. Health policy is not only regarded as a pre-condition for economic growth, in fact, it is increasingly considered as the locus where business interests and economic growth can be realised. The potential benefits of existing policies on patient and health professional mobility to alleviate the crisis-induced problems of unemployment and reduced access to care must be weighed against growing problems of brain drain and resource outflow for those countries most affected by the crisis.
Broader ‘contradictions and challenges’ of subsidiarity, power asymmetry between economic and social goals and social cohesion (Mossialos et al., Reference Mossialos, Permanand, Baeten and Hervey2010) are likely to be touched by these developments. First, subsidiarityFootnote 7 as a political principle means that the EU may only act in health policy when there is clear added value to single MS actions. Whenever the EU becomes progressively involved in policy areas such as health system policy one can question if a shift in competence distribution in favour of the EU is taking place. Despite a growing health care agenda at EU level, the subsidiarity principle seems to be untouched from a health policy perspective. Financing schemes provide ‘incentive measures’, which include multiple opportunities for national decision makers to change or block the incentives set by the EU. Other instruments outline a role for the European Commission rather as a facilitator or an arena for the cooperation and exchange of MS. MS will stay in the ‘driving seat’ of health care organisation. Nevertheless, by having the opportunity to frame agendas and steer discussions, this can change national policies and align national practices increasingly in a way that the ground for future hard laws might be prepared (Hervey and Vanhercke, Reference Hervey and Vanhercke2010). MS do not perceive a higher efficiency in regulating health care system aspects at EU level to be so high that they would give up their regulatory competences in health system organisation.
Beyond the EU's health care agenda, potential pressures on the subsidiarity principle in health policy might arise from the emerging fiscal governance framework. The strengthening of the Stability and Growth Pact involves inter alia stricter and independent monitoring of national households and a limit to the structural deficit by 0.5% of the gross domestic product. Additionally, ‘peer pressure’ is encouraged by the ‘European Semester’ to improve macroeconomic coordination among Euro countries. The practical relevance of establishing a EU fiscal union for health systems cannot be fully estimated at the time of writing. However, discussions have started on what degree budgetary control will impinge on national health system budgets and thereby affect the subsidiarity principle in place (Lamping, Reference Lamping2012). Consequently, from a health policy perspective, it appears that the EU's responsibilities in health care organisation will remain limited in the near future.
Subsidiarity affects another contradiction inherent in EU health policy relating to the asymmetry between economic and social responsibilities at EU level. Market integration and liberalisation have been successfully Europeanised, but EU social integration has been limited by the diversity of national social security systems (Scharpf, Reference Scharpf2010). To identify the uptake of supportive health objectives as a move towards social priorities is tempting because of the increasing pre-occupation with health policy targets at the EU level. However, the attainment of health care policy goals is very much linked to economic goals. The replacement of the Lisbon Agenda by the EUROPE 2020 strategy in 2010 was accompanied by a shift in balancing the economic vs the environmental and social pillar of the Union with a changing emphasis in favour of the former. The Lisbon Agenda regarded social and environmental objectives in addition to economic objectives as goals in their own right, but nevertheless connected – as prerequisites for growth and employment objectives. In contrast, with EUROPE 2020 regarded as an ‘exit strategy’ from the crisis are ‘social and sustainability concerns now explicitly put at the service of growth as growth enhancing factors’ (Bongardt and Torres, Reference Bongardt and Torres2010: 139). This has certainly influenced the formulation of new health policy initiatives at the EU level as we have seen with the proposals for a SF Regulation and the 3rd Action Programme starting in 2014. Despite growing attention for health and social priorities, it is sought to achieve economic goals at the same time. Thus, asymmetry is still in place in the formulation of EU health policies.
Moreover, since the effects of market liberalisation are supposed to differ across regions, economic integration has necessitated the promotion of social cohesion. EU cohesion policy with regard to reducing regional disparities, has addressed health inequities by supporting health system and public infrastructure. As the crisis hits countries to a varying degree, the achievement of social cohesion in the European Union is becoming more difficult. Moreover, the EU policies on free movement and financial schemes to be applied in health systems might even intensify socio-economic differences. First, free movement of health professionals and patients might hit economically weaker countries more and benefit economically stronger countries. Second, those regions and countries most affected by the crisis will find it comparatively more difficult to demonstrate the benefits for businesses and the economy in the application for EU funds. In a situation where national austerity measures incorporate major cuts in health system and other public expenditure and general tax increases, the prospects of health system strengthening and economic growth will be hard to make. This runs counter the actual need for public and private investments to be made in those regions and countries. Hence, it remains doubtful if health policies can make a difference to growing economic and health inequalities despite social cohesion goals incorporated in EU policies.
4 Conclusions
Fahy's asked ‘Who is shaping the future of European health systems?’ (2012). We have provided an initial analysis of how health systems will be influenced by the EU's health policy agenda in the future. Financial support and the facilitation of an arena for cooperation by the European Commission are not neutral. EU involvement adds new layers to the discussion of health policy such as questions of subsidiarity or EU wide social cohesion. In addition, national and EU agendas on health care systems differ in the degree to which economic and social goals are balanced. The discussion and comparison on the EU level of measures to counteract health-related effects of the crisis and additional EU funding opportunities for health system should be welcomed. Nevertheless, EU involvement can add biases and problems previously unknown at national levels. This is not only important for the response to the crisis but also in light of more long-term discussions on and challenges to redesigning health system in addressing the effects of the demographic change. Every policy needs further careful attention concerning its added value and potential drawbacks in later stages of the policy process.
In addition, our analysis raises questions on the implications for EU health policy as such. Do we witness the emergence of a critical juncture as Greer (Reference Greer2008) has described earlier for EU health policy? The predominant narrative for discussing health system issues on EU level is still undecided. A health rationale has co-existed so far with a social and economic policy perspective at EU level and the crisis has likely added a financial consolidation rationale to it. The financial crisis might lead to one of them becoming the prevailing discourse for health policies discussions and alter the institutional design of health policy at EU level. This could indicate the current patchwork character to dissolve and EU health policy to be more coherently addressed from a health – or from one of the alternative logics. However, a path-dependent route continuing with multiple logics for health policy making cannot be precluded so far.
Finally, what does this mean for the regulators, providers, purchaser and patients in European health care systems? The increasing occupation with health system goals at EU level can lead via networking, learning and consensus building among decision makers in Europe to very practical effects (Greer and Vanhercke, Reference Greer and Vanhercke2010). Although it is too early to see them now, we might have entered a long term process ‘From Cooperation to Convergence’ (Peeters, Reference Peeters2012: 56) towards a Europeanisation process of health systems in Europe.
Acknowledgements
The authors are grateful to the two reviewers and the colleagues of the Department of International Health at Maastricht University for their valuable comments on earlier versions of this paper.
