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Health governance in Europe

The politics, policy and governance of health in the EU

Reforming the European Semester for health – what role for civil society?

On 28 November 2014 the European Commission announced its plans to reform the European Semester, the EU’s annual cycle of economic policy coordination. This initiative comes in response to sustained monitoring and evaluation which suggests that the recommendations made as part of the Semester, known as the Country Specific Recommendations (CSRs), are not being implemented sufficiently at national level, due to ‘lack of ownership’. For health, this problem has been particularly acute, with almost all member states achieving ‘limited’ or ‘no progress’ in implementing health-related CSRs. How then can the Semester be reformed to ensure that constructive recommendations are published and implemented in coming years?

The European Semester implements the Europe 2020 Strategy, which seeks to generate smart, sustainable and inclusive growth. It is launched by the publication of the Annual Growth Survey (AGS), in which the Commission lays out the economic priorities for Europe in the coming year, issued each November. The AGS is designed to be used by member states when crafting their plans for fiscal policy and structural reform, which must be submitted to the Commission in March/April for evaluation by the main institutions. On the basis of these and a series of other documents and reports, the EU then issues each member state with a set of Country Specific Recommendations (CSRs), detailing specific policy suggestions which are to be taken into account when drafting national budgets.

This process seems somewhat distant from health but in fact has a substantial impact upon national and European health policy. In each successive cycle the CSRs have included increasingly detailed health-related recommendations to a growing number of member states. These recommendations range from broad and vague suggestions such as ‘work to increase the cost efficiency of public expenditure’ (Austria, 2014 CSR) to specific and targeted instructions to ‘set more ambitious annual healthcare spending targets’ and ‘take steps to tackle the increase in public expenditure…in the area of pharmaceutical spending’ (France, 2014 CSR). Whilst the CSRs are non-binding for countries not in receipt of financial assistance, compliance and implementation is monitored by the Commission and governments are subject to increasing pressure from the EU institutions to heed the suggestions made.

Now in its fifth cycle, the European Semester has been amended and revised in response to flaws in its early working, yet significant concerns remain. Provision for the meaningful participation of national parliaments, social partners, trade unions and civil society organisations (CSOs) is woefully insufficient. Though the Commission’s current plans for reform acknowledge the importance of involving ‘national Parliaments, the social partners and civil society at large…in the implementation of policies’, on specific provisions for dialogue as a part of the drafting process in crucial documents, it mentions only the two former stakeholders. Civil society is set to remain largely excluded unless it can mobilise to assert its right to participation and its added-value as a contributor.

How then can the Semester be reformed to ensure involvement of all appropriate stakeholders, adequate implementation of recommendations by member states and improved health outcomes for Europeans? Ensuring a balance between social and economic objectives in a governance framework designed only to target the latter is a challenging task, but positive initial steps have already been taken. Previous reforms have made way for a greater role for the European Parliament and almost all commentaries and assessments now acknowledge the need to extend such systematic participation to social partners, national parliaments and, in some cases, CSOs. An important step noted in the Commission’s current plans is the simplification and increased flexibility of the Semester’s time frame. Stakeholders have commonly complained that, with limited resources, the tight schedule in which the plethora of Semester documents are drafted, discussed and issued makes meaningful participation virtually impossible. A reduction, simplification and relaxation of this process will go a long way to facilitating civil society involvement.

In critiquing and lobbying the Commission’s planned reforms CSOs should be mindful, however, of their own responsibility in fostering ‘meaningful participation’ within the Semester process, and the EU policy-process more broadly. The best way to guarantee inclusion and impact in a given process is to ensure that the contribution made is clear, relevant and brings added-value. This is even more important for civil society, whose resources are often thinly stretched and cannot afford to be misapplied. Overly-long written contributions, poorly-timed public events, mis-targeted media campaigns and irrelevant interventions waste valuable time, investment and credibility, damaging longer-term prospects for participation.

The Commission’s proposed reform of the European Semester is welcome and overdue, but imperfect – as such it presents a critical window of opportunity for civil society to coordinate, mobilise and work together to effect a change. Mutual building of capacity and sharing of resources is vital if provisions for meaningful and inclusive participation are to be ensured and the European Semester is to be recast as a tool for strengthening Europe’s health systems.

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