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Boosting Europe’s resilience with better health systems: Lessons from the COVID-19 crisis

Healthcare / COMMENTARY
Claire Dhéret , Simona Guagliardo

Date: 14/04/2020
The EU and its member states must learn from the current pandemic if they are to improve their health systems and build up their resilience before the next one hits. Lesson nr 1: exclude social investment from public deficit calculations. Lesson nr 2: make the convergence of working conditions a key objective of the Single Market, with a specific focus on health professionals.

The COVID-19 pandemic is putting health systems across Europe under enormous strain. The unprecedented surge in demand for intensive care is rapidly bringing health systems to a breaking point. Health workers are stretched thin and medical resources are becoming scarce.     

However, European countries are not impacted to the same extent, thus revealing uneven capacities to cope with this external shock. While solely blaming the EU would be misguided, and there is obviously a need to, first and foremost, deal with the immediate effects of the pandemic, the EU must learn from this crisis and reflect on how its member states can become more resilient to future pandemics.

This calls for a profound change of mindset. Firstly, the EU should implement measures that allow for the development of social investment strategies at the national level, including crucial changes to how public deficit is calculated. Secondly, it should complement the Single Market with social convergence measures and ensure fair working conditions everywhere in Europe, particularly in the health sector.

 Uneven public health systems

The capacity of health systems to cope with this emergency is not equal across Europe. Member states are differently equipped in terms of staff, medical appliances and facilities.

Hospital capacity, for example, varies starkly across EU countries. Before the crisis hit, Italy and Spain – the two hardest-hit countries in Europe so far – could count on, respectively, 12.5 and 9.7 critical care beds per 100,000 inhabitants, while Germany stood at 29.2.[1]

Then there are the staff shortages in the health sector. Despite an increase in the absolute number of physicians and nurses over the last decade in Europe, it has not been enough to respond to the increase in demand for care. Even less so in times of a pandemic. When comparing countries, it becomes apparent that, not only do some have up to five times more nurses than others, the number of physicians also differs considerably. Greece and Austria, for example, have 6.1 and 5.2 physicians per 1,000 inhabitants respectively, while Poland and Romania have less than 3.[2]

National health systems are also dealing with the current crisis very differently. For instance, there are differences in testing strategies across Europe. In Germany, for example, around 40,000 tests are currently performed daily with increasing tendency. Until 5 April, Spain’s daily testing capacity was standing at around 15,000 to 20,000.[3]

These factors explain – even if only partially – why frontline services are more overwhelmed in some countries than in others.

Is the EU at fault?

Although healthcare services fall under the responsibility of national authorities, their capacity to address their public’s needs can be impacted by EU policies – or the absence of them.

In the context of the European Semester, the Union’s framework to coordinate economic policies across the member states, countries can receive country-specific recommendations in the area of public health. While they are often asked to strengthen the quality, accessibility and affordability of their health systems, many of them are also required to improve their cost-effectiveness and fiscal sustainability.[4] Furthermore, in countries which were under bailout programmes in the aftermath of the financial and economic crisis, EU financial support was conditioned upon the introduction of public reforms entailing debt reduction. In many cases, national health systems were the first to undergo significant cuts, which might have undermined their resilience.

Sharp differences in health system capacity can also be exacerbated by labour migration. Doctors and nurses are by far the most mobile professionals within the EU. In the last decade alone, almost 85,000 doctors and more than 90,000 nurses obtained their qualification in one country and applied to work in another. The flows mostly go from Eastern and Southern Europe to Western and Northern Europe. Romania, Greece and Italy form the top three of ‘doctor exporting’ countries; Romania (again), Spain and Portugal the top three of ‘nurse exporting’ countries.[5] This migration is mainly triggered by differences in working conditions, including higher earnings and better working environments in Western and Northern Europe.

This brain drain has had severe consequences for the countries of origin: decreased access to care, less resilient health systems, higher unmet medical needs and poorer health of the population. The scourge of a pandemic exacerbates this situation, drastically reducing health systems’ ability to bounce back. However, all hope is not lost. There are instruments that both the EU and its member states can put in place to mitigate the effects of labour migration in sensitive sectors like health.

Member states: Stop the blame game and act responsibly     

Blaming the EU for the uneven capacity of public health systems to cope with the current crisis would be misguided. Today’s media headlines too often deride the ‘useless EU’, or its ‘insufficient’ reaction to the pandemic. This discourse plays into the hands of populist and Eurosceptic forces while ignoring what actually falls within the purview of the EU, which is very limited in the health area.

It is therefore time for national policymakers to shoulder responsibility and stop playing the blame game. In fact, even if some EU policies have had negative spillover effects on national health systems, as indicated earlier, they do not prevent countries from improving the working conditions of health professionals and creating incentives for them to work in their country of origin.

In the same vein, there is no inherent opposition between balanced public budgets and well-performing health systems. Rather, achieving this twofold objective is the result of a set of comprehensive measures, including political choices, prioritisation, smart social investment and sound public finance management.

Member states have numerous instruments at their disposal to improve their health systems. Although in principle they can build well-performing structures, in practice their leeway to invest and innovate is reduced when they suffer from high levels of debt. Nonetheless, the current context of crisis highlights the importance of having resilient societies, regardless of a country’s level of public deficits.

Turning the EU into a driver of resilient societies

Evidently, the urgent priority is, and rightly so, to limit the number of casualties, protect health systems and professionals from an influx of patients (that could rapidly get out of control), and develop and roll out an ambitious economic recovery plan as fast as possible. However, once the immediate management of the crisis is over, time and attention must be spent on collective reflection at both the European and national levels.

What are the lessons the EU, in particular, could learn from this crisis?

Firstly, current events remind us of the importance of social investment, or investing in crucial segments of the public sector, health being one of them (alongside education). By becoming an ‘agent’ of social investment and more resilient societies, the EU could strengthen the entire stability of the Union.

An important first step would be to adopt  a new approach to calculating public deficits by not including investments that are clearly targeted to modernise, equip and strengthen vital parts of the public sector, especially the health system. By doing so, abiding by the rules of the Stability and Growth Pact would no longer foster low levels of investment in what, at the end of the day, determines the resilience of European societies and thus their ability to cushion the effects of severe crises.

Furthermore, the EU must ensure that cuts in national budgets and health reforms are accompanied by strong investment in innovation, which in turn can contribute to enhancing the effectiveness, accessibility and affordability of European health systems.[6]

Secondly, it is fundamental that the EU further complements the main principles of the Single Market, including freedom of movement, with social convergence measures. While this is one of the greatest achievements of European integration, it can also undermine the capacity of individual countries to face external shocks. Thus, the EU must  embark on a process of social convergence proactively. Leaving it in the hands of (single) market forces has not yielded the expected outcomes.

Implementing the European Pillar of Social Rights (EPSR) in all members states will be an important step in this direction. But given their uneven efforts to deliver on the EPSR, this will also require some coordination mechanisms at the EU level, not least the improvement of working conditions. The Commission’s plan to provide a fair wage to all workers while reinforcing social dialogue can translate into positive outcomes for thousands of health workers suffering from poor working conditions. Achieving a political agreement on this instrument must therefore be a key priority.

The current crisis reveals the decisive role social investment and crucial segments of the public sector play in making European societies and economies more resilient to external shocks. At the same time, it highlights, once again, member states’ close  interdependence and, consequently, the collective responsibility and joint interest to build a stronger Union together.

Delivering on this objective requires both a swift and ambitious economic recovery plan as well as resilience-building, which will enable individual member state to buffer shocks. This means that the EU should put parameters, such as social investment and the quality of the public sector, on an equal footing with macroeconomic indicators. By failing to combine these two complementary approaches, the Union will miss this opportunity to come out of the crisis stronger and better equipped for the future.

Claire Dhéret is Head of the Social Europe & Well-being programme. Simona Guagliardo is Policy Analyst in the Social Europe & Well-being programme.

The support the European Policy Centre receives for its ongoing operations, or specifically for its publications, does not constitute an endorsement of their contents, which reflect the views of the authors only. Supporters and partners cannot be held responsible for any use that may be made of the information contained therein.

[1] Rhodes, A.; P. Ferdinande, H. Flaatten; B. Guidet; P.G. Metnitz; R.P. Moreno (2012), “The variability of critical care bed numbers in Europe”, Intensive Care Medicine, Volume 38, pp.1647-1653.
[2] Authors’ own calculations based on latest the Eurostat data. See Eurostat, “Health > Data > Database” (accessed 07 April 2020).
[3] COVID-19 Health System Response Monitor, “Homepage” (accessed 14 April 2020). It should be noted that all countries are stepping up efforts to increase their testing capacity quickly, so figures evolve very rapidly. Spain, for example, acquired a batch of five million rapid COVID-19 diagnostic tests and distributed around two million to its regions over the past week (Ministerio de Sanidad, Consumo y Bienestar Social, ‘Notas de Prensa’, accessed 14 April 2020).
[4] See European Commission, European Semester: Commission proposes health recommendations, 05 June 2016.
[5] Authors’ own calculations based on the European Commission. See European Commission, “Regulated Professions Database” (accessed 07 April 2020).
[6] See European Commission, “The State of Health in the EU” (accessed 07 April 2020).

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