Pushing the Global Health agenda at EU level: Challenges and opportunities
Author: Lisa Ploeg
Affiliation: Maastricht University
Publication date: March 5 2016
In today’s world, health is increasingly recognized for being shaped by a multitude of factors that relate to the world we live in and the way we live in it. Without debate, our social, economic and environmental surroundings, and the complex range of policies in those fields impact our health. In an increasingly globalizing world, these environments continue to change and their impact therewith, demanding tailor-made responses towards creating resilient populations and communities (Woodward, Drager, Beaglehole, Lipson, 2001).
The European Union, with over 500 million inhabitants – and with an eye on enlargement and thus growth – faces these health challenges within its territories, especially with its structures that facilitate the free movement of people, goods and services throughout the Union. However, it is also of utter importance to consider the role the EU plays and can or shall play as an actor in global health. Where within the EU the structures and competencies for health pose a complex picture, the health impacts of its policies at global scale surpass this complexity even more (Aluttis, Krafft, Brand, 2014).
1.1 Background: Illustrations for Global Health importance
An important facet when thinking of the importance of global health is communicable diseases. Taking the example of influenza pandemics, it is commonly understood that global research and development must ensure that pandemic vaccines and drugs can be quickly available, and that understanding of a particular virus evolves at rapid pace in times of crises (WHO, 2006). The WHO has created recommendations in 2005 to its members, to develop or update their influenza pandemic preparedness plan (WHO, 2005). A review by Straetemans and colleagues (2007) looked at prioritization strategies for pandemic vaccine capacity in WHO Member States. The study concluded that most countries had prioritization strategies, with defined vaccine priority groups. However, in most plans the criteria on which these groups are identified were not clear, and merely ten countries had consulted ethical experts to guide the decision-making process for vaccine prioritization (Stratemans, Buchholz, Reiter, Haas, Krause, 2007). This imbalance, although seemingly small, can have major consequences at times of outbreaks, and hinders the development of well-planned scenarios and measures to take. A milestone event that has prompted the need for countries to commit to global health is the SARS outbreak in 2003. Interdependencies at global level became clear as the transmission of the disease across boarders took place very rapidly (Ruan, Wang, Levin, 2006). The outbreak forced policy makers in the EU and other places to expand their scope beyond their borders, and indeed, global health initiatives were taken afterwards, as will be discussed further in this paper.
Another concern for global health is the development of medicinal products. The EU has a centralized procedure for approval of new medicinal products. However, disparities within the EU occur because of the fact that the centralized procedure is not mandatory for all human use medicinal products, and different authorization procedures in the Member States lead to heterogeneity in approval. Furthermore, the pharmaceutical market is increasingly criticised for not being able to ensure innovativeness of medicinal products and anticipate unmet consumer demands and needs (Catala-Lopéz et al., 2010). Moreover, granting market approval does not mean an improved availability to medications and, also in the global perspective, access to medicines is simply far from harmonized. Pricing and reimbursement mechanisms remain country considerations and thus align to governmental structures, policies, and public health systems and resources (Garattini, Bertele, 2002). Especially low and middle income countries mark these differences in access, and deaths from communicable diseases that are preventable and treatable occur in magnitude.
Therefore, several authors invite pharmaceutical industry leaders and policymakers on both EU and global level to consider these imbalances and the implications in setting future public health priorities (Catala-Lopéz et al., 2010). New questions regarding this issue are likely to soon arise, with the Transatlantic Trade and Investment Partnership (TTIP) being implemented. Whilst this paper will not focus on this partnership, it is of critical importance to be aware of it and think how it may change coordination for global health issues. Not only would it impact the pharmaceutical market with free trade partnerships, but also broader public health matters, including food safety and agriculture (EPHA, 2015).
This paper aims to draw an overview of current structures regarding the EU’s role and commitment to global health and the challenges in place, in order to identify where opportunities lie for the EU to go forward with global health higher on the agenda.
2. State of the art: Global Health on the EU agenda
2.1 Current coordination
Within the structures of the Union, global health policy is mainly coordinated through an internal global health task force in the Commission, in which three DGs take part and rotate chairs: DG DEVCO, DG SANTÉ and DG RTD. Other DGs which have a role in global health are also members, such as DG Agriculture and DG Trade. In the Council, global health policies are mostly dealt with under development and trade and under the Foreign Affairs Council (Action for Global Health, 2010).
The European External Action Service (EEAS) is a newly formed body, representing the EU through delegations in third countries. Their mandate includes part of the operational authority for global health policies, and it will take over the lead of the EU’s relations with international bodies such as World Bank, IMF, WTO (Action for Global Health, 2015).
2.2 Current developments
As a starting point to view where the EU is now in terms of global health, one can look at the first Health Strategy ‘Together for Health’, that depicts the key directions of EU health policy between 2008 and 2013. One finds that the importance of global health has been acknowledged and highlighted within the Strategy’s four core principles for action (European Commission, 2007):
1. A Strategy Based on Shared Health Values
2. “Health is the Greatest Wealth”
3. Health in All Policies (HiAP)
4. Strengthening the EU’s Voice in Global Health
The strategy also stated the difficulty of separating national and EU level actions from those in the global context, as community and global health impact each other in both directions. The strategy confirmed that, while public health remains the main role of Member States, sovereignty principles have emerged over public health issues that go beyond borders, not to mention the free movement of goods, services and people (European Commission, 2007). Besides the fact that global health thus specifically came forward in the strategy, it was less apparent in the implementing instrument, the European Health Programme (Aluttis, Krafft, Brand, 2014). However, the European Commission established a policy framework for action in a communication entitled ‘The EU role in Global Health’ (European Commission, 2010), which was supported by the corresponding Council Conclusions (Council of the European Union, 2010). The framework recommends solutions to global health that are systems based, rater than diseases specific, meaning the desired type of approach that encompasses implementation of the policy by including different directorates – e.g. health, development, and research – cooperating for global health. As it was stated, ‘addressing global health requires coherence of all internal and external policies and actions based on agreed principles’ (European Commission, 2010).
The idea of creating systems based policy solutions, relates again to the Health Strategy, where the principle of ‘health in all policies’ (HiAP) shall not be overlooked in light of global health. Health in all policies provides the main indication for health moving up on the agenda of other policy fields, such as foreign affairs. It necessitates the health sectors to cooperate with other sectors, demanding improved coordination within the EU on global health governance (Battams, Schaik van, Pas van de, 2014).
In addition to having global health on the agenda within the EU, it is noteworthy that the dialogue on development between the EU and US has also become increasingly effective. In 2011 in fact, a joint EU-US taskforce on health was created with an eye on the MDGs for 2015, bringing together experts to identify areas of cooperation between the EU’s global health policies and the US initiative on global health (Bliss, 2013). Strengthening health systems in partner countries in the developing world is one of the current priorities. As health is not one of the core competencies of the EU’s development priorities, where climate change and food safety are, the taskforce seeks to raise these issues and promote an exchange of best practices (Bliss, 2013). As Bliss (2013) further argues in her book, the time has come to create a Health Diplomacy Strategy. With the current and developing economic challenges, it is argued that “now is both the time for traditional European donors to drive innovation and for emerging economies to embrace their new roles as partner donors.” Strategies shall then gain effectiveness, and new frontiers will be built to enhance awareness and synchronize coordination mechanisms along new trends. (Bliss, 2013)
2.3 Main challenges
Taking into account the latest developments towards the creation of a common policy framework for global health, the EU can be considered a significant player in the field. Throughout the past years, it has positioned itself stronger in international health negotiations and increased its impact on agreements. However, the agenda for global health is still an unfinished one, challenges continue to be significant and thus the question remains why global health policy frameworks are not yet implemented and in place (Rollet, Chang, 2013).
Several authors argue that the Treaty of Lisbon has limited the impact, as it would present challenges for policy coherence and the effectiveness on health issues. Coherence is an issue in both the discussion regarding the extent of competence for health between MS and the EU, as well as the one regarding the links of health with other policy areas and directorates across the EU (Battans, Schaik van, Pas van de, 2014). However, rather recently, the EU obtained speaking rights at the United Nations General Assembly (UNGA), where foreign policy actors representing the EU can now engage in debates, make proposals and oral amendments, and have a right to circulate documents in meetings and reply, amongst other. With these rights, the EU’s role for global health governance within the Assembly is likely to increase, as social determinants of health can be recognized, making it more prone to be an issue on the foreign policy agenda (Battans, Schaik van, Pas van de, 2014). However, it shall be noted here that increasing competence and extending the role of the EU on the UN or WHO structures is limited or will be contested. This is mainly due to the fact that MS have been reluctant to cede competence to the EU, as their views on health issues are too divergent at this level, which has again become mostly clear after the enforcement of the Lisbon Treaty.
Indeed, the EU is less influential in the area of global health compared to other policy areas such as environment or trade. This is caused by indistinctness of the health acquis, and the ongoing discussion about competences. Additionally, on the foreign policy agenda, global health is still prioritized low (Battams, Schaik van, Pas van de, 2014).
Moreover, the large variety of different actors that operate within global health is an important implication towards reaching good governance, and poses additional challenges to the EU as to how to position itself in terms of leadership. It has been argued that global health governance is fractured, and NGO engagement is split. International institutions involved in agenda setting have a variety of visions regarding the role of the WHO and platforms and alliances are segregated between the public and private sector.
Another issue that hinders the further development of global health on the EU agenda, is the lack of a common definition and understanding of the term. Especially in consideration of the aforementioned multitude of actors and institutions in the global health arena, having a comprehensive definition and focus of global health is crucial for initiatives to remain appealing and retain a high level on policy agendas. The foregoing Commission communication on ‘The EU role in Global Health’ defined global health to be about ‘worldwide improvement of health, reduction of disparities, and protection against global health threats -…- addressing global health requires coherence of all internal and external policies and actions based on agreed principles’ (European Commission, 2010). Despite an attempt to define global health, a comprehensive global health focus in EU actions is lacking and might explain why global health has lost its prominent position on the EU agenda (Aluttis, Krafft, Brand, 2014).
3. Discussion of opportunities
Having discussed some of the main challenges in positioning global health more on the European agenda, it is noteworthy to depict some of the opportunities that facilitate this. Europe remains in a good position to actually take the lead in global health, especially when it comes to areas such as research and innovation. Health is in fact the largest industry in most EU countries and continues to grow, which enables Europe to take a unique opportunity for scaling up to having a more prominent role to move global health forward with research and innovation (Battams, Matlin, Jahn, Kickbusch, 2011). Increasing investments for global health are a necessity for the EU to ensure leadership in innovations and health research.
However, not only should arguments for global health on the EU agenda focus on what the EU has to benefit. Thinking in terms of desirability for global health priorities also means being aware of what the EU has and wants to offer on a global scale. For example, the EU has its strong values for health – universality, access to good quality care, equity and solidarity – that make one wonder; why not demonstrate and disseminate these on the global agenda? Although a common definition and conceptualisation of global health may not be in place yet, promoting agreement on common values and principles to work with could be a major step towards it. The limitation of the conceptualisation of global health would then not be seen as a roadblock so much, rather would it create an opportunity to work on reaching citizens and level their rights to health.
Talking about citizens, the role they play in EU agenda setting cannot be overlooked. In the policy or law making process, for example, the European Commission can initiate policy, where one of the first phases includes the launch of a Green Paper. As Green Papers serve as discussion documents, describing a range of policy ideas, they aim to stimulate debate and launch public consultation. This forms the opportunity for individuals and stakeholders or interest groups of all kinds to engage and shape the draft of the proposal before it is passed on to the Council and Parliament (EUROPA, n.d.). A common finding is that citizen engagement in these opportunities is often rather low. However, global health is a policy topic where the mass of the population feels committed to, just as in development or humanitarian aid, and would be keen to express their views. Moreover, a multitude of health stakeholders, private foundations and public-private partnerships are engaging in global health and funding for global health initiatives has increased significantly. However, governance issues are now found to often stand in the way and deserve more attention, particularly in areas dealing with the social determinants of health (Battams, Matlin, Jahn, Kickbusch, 2011). Thus, where civil society can be provided with more transparency in decision-making, clearer lines of accountability and fairer democratic participation can be assured, there is more scope, awareness and willingness for individuals to act. Additionally, responsiveness in public consultations – to name an example – could be enhanced, providing a strong power mechanism to have society impacting agenda setting on EU level. And, again, by empowering its own citizens to engage more, a new opportunity opens to therewith enforce the strength of the EU’s core values for health, where citizens show them with conviction. Ultimately, this would lead to increased recognition of expansion on a global scale.
Another main challenge following citizen empowerment and increasing multilateral engagement of actors on global health agenda setting, is the difficulty to create one single EU voice. When thinking about positioning the EU and strengthening global health issues on the agenda, one would easily stress the need to have one single voice. However, reconsidering this idea one could agree with Battams and colleagues (2014), that this may mean having a ‘lowest common denominator’ position. In other words, aiming for a single voice with such differing positions between MS – and other stakeholders and actors – would merely create a single voice with a very limited scope to be concise and realistic to achieve. Therefore, soft power and soft diplomacy are becoming increasingly important in global health diplomacy and it is these mechanisms that have potential to enhance EU influence on global health.
Governing health in today’s world is and will be an astoundingly complex endeavor. The EU has become an increasingly strong actor in its role in global health, yet global health is currently not very high on the agenda, nor are actions taken satisfactory at this time. However, being aware of the EU’s significant potential, the time is now not to wait for another public health emergency to appear where swift action is suddenly needed. Thinking back of how the current policy framework for global health came about – following the antecedent SARS outbreak in 2003, that forced policy makers to look beyond borders – it is now time to think in steps ahead. Exploring opportunities is fundamental, for example by being a leader in research and innovation for health, which will create competitive advantages. Another key point lies with its citizens and society, raising a voice and pressuring for global health, whilst representing the values we attach to it. Moreover, it is essential to keep working on a common definition of global health and aligning work across different levels and with different actors accordingly. This will create a clearer focus on the road to take, enabling global health to be better pushed on the agenda and action more easily and likely to be taken at times of need. Additionally, this will increase credibility with regard to the role and commitments the EU purports.
The EU is in a privileged position to take up global health as a priority. If it can manage the diversity in health and health policy across its own Member States, it can certainly promote the skills needed for this at global health level. With new forms of diplomacy emerging and health being increasingly recognized as shaped by different policy areas, it is now time to expand health onto other agendas, including foreign policy, and become aware of the benefits of including global health in it.
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