Public health in the EU: 30 years since the Maastricht Treaty

Much of the evolution of public health in the EU is owed to the impact of health crises in the past three decades. Looking forward, one thing is certain: the future of EU public health policy depends greatly on the political will of member states.

The recent European Policy Centre’s Coalition for Ethics Health and Society (CHES) and Maastricht University event traced the evolution of public health in the EU, taking stock of the developments and changes since its signing in 1992. From former and current representatives of the European Commission and Members of the European Parliament to health NGOs, academics and citizens, the speakers reflected on the current state of play of public health in the EU before exploring the possibilities for the future of health in the EU.

The evolution of public health policy in the EU

“Europe will be forged in crises and will be the sum of the solutions adopted for those crises.” These words penned by Jean Monnet were echoed during the event. The idea of a Europe forged in crisis holds undoubtedly true for public health and was a sentiment shared by panellists during the first session of the conference, which reflected on the past three decades of public health in the EU. The Union has encountered its fair share of public health crises, from the 2002 SARS outbreak to the 2009 swine flu pandemic and, of course, COVID-19. Each has had its own impact on the EU’s role in health policy, from the formation of the European Centre for Disease Prevention and Control in 2004 to joint procurement and now the construction of a European Health Union.

The notion that it is not the law that shapes society but vice versa was prominent during the conference, as speakers reflected on the evolution of public health policy in the EU since its first mention in the Maastricht Treaty. But while much has changed, many questions remain regarding the EU’s competencies and role in public health. Indeed, even the stakeholders are still figuring out what exactly health in the EU means. While healthcare is a member state competency, the permeability of the principle of subsidiarity and indeed the flexibility of Article 168 TFEU could allow for further cooperation. This is entirely dependent on member states’ political will and ambition, as emphasised strongly during all panels of the conference.

It was also argued that the future focus of EU health policy should not be on only health-specific policies but rather broader. Breaking down silos within the institutions and policy areas could improve health outcomes. “Health in All Policies” is an approach that has been around since the Finnish EU Presidency in 2006, but this should now shift to ‘All Policies for Health’, integrating health impacts into policies like climate action and migration. Health should be viewed as an intrinsic European value and be at the fore of Europe’s self-image. As long as the EU strives to be perceived strongly from the outside, its internal fortitude must be up to par.

The state of health in the EU

While there have been ad hoc solutions to the EU’s various health challenges, it was the outbreak of the COVID-19 pandemic which created a new political momentum in health policy. While reflecting on today’s state of health in the EU, speakers in the second panel conveyed that member states quickly realised that they could not fare the pandemic alone and that the strength of EU cooperation and coordination was apparent. One of the EU’s strengths, particularly in health policy, is its ability to deliver what cannot be done at the national level. Speakers hailed the vaccine strategy as a success, emphasising the creation of equity as citizens across the EU all had simultaneous access to the vaccinations.

The success of the vaccine strategy raised the question of whether joint procurement could be used in other areas of health policy, such as medicines for rare diseases. The common negotiating practices would create a more level playing field and fair access to medicines and treatments for citizens across the EU. Although the vaccine strategy may have successfully promoted equal access, the principle of equality between member states was noted as otherwise lacking. Speakers discussed the issue of continuing divergence in standards between member states when it comes to healthcare. This is intolerable due to the inequalities it creates, particularly in terms of accessibility.

Speakers stated that the added value of increased EU involvement in health policy should translate to equity in accessibility and affordability. However, without willingness from member states, this will be difficult to achieve.

While each of the 27 member states determines its health systems and policies, the external perception is that the EU is one entity, even in healthcare. The need for global cooperation was discussed, with the assertation that ‘slowbalisation’[1] is much more of a reality than deglobalisation.

The future of health in the EU

The uncertainty of national political will to advance the EU-level health agenda greatly contrasts with citizens’ views, as expressed during the third panel. Via the Conference on the Future of Europe, citizens called for a more social Europe, with increased EU competencies in health policy. Panellists discussed the possibility of raising said competencies through treaty change, but a consensus was not reached, with some arguing that treaty change is actually not necessary. Instead, majority voting could address some of the noted challenges. The question about treaty change will always be followed up by another: What for, exactly? It was suggested that the focus should be on what the EU and member states can do better together, such as sharing and adopting good practices, exploring avenues for cooperation in vaccines and medicines procurement, cross-border healthcare and global health policy.

Those advocating for treaty change argued the need to make legislative processes faster, to achieve better health for citizens. In general, speakers highlighted areas that should be prioritised at the EU level to create a resilient European Health Union. These include sustainable and outcome-based health systems, the well-being of healthcare workers and the digitalisation of healthcare. The latter was discussed in the first and last panels, particularly in the context of the European Health Data Space (EHDS). This new initiative’s potential is evident, but the need for a flexible framework for member states’ implementation was highlighted, as was the need to foster citizens’ trust in and understanding of how their health data is used.

If EU public health is forged in crisis, and as we emerge from the pandemic, how will its future look? The EU4Health is the largest EU health budget ever. But going forward, how can – and should – it be utilised to achieve the greatest health outcomes for EU citizens? Such questions are set to stay as we determine what treaty change could mean for health policy in the EU in the years to come.

Nevertheless, what was apparent from this conference is that the future of health in the Union very much depends on the political will of member states. For health reforms to succeed, be it with or without treaty change, policy proposals must be specific and clearly have an added value for EU policymaking.

Danielle Brady is a Junior Policy Analyst in the Social Europe and Well-Being programme.

CHES is kindly supported by a non-restricted education grant from Johnson & Johnson and the EPC’s Social Europe & Well-Being programme.

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[1] A phenomenon which involves a slowing down of the pace of global integration.