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Health governance in Europe

The politics, policy and governance of health in the EU

EU governance 3.0 – in search of a characterisation

The economic governance framework, established by the EU since the crisis and recession of the late 2000s, presents a new paradigm within which health policy must operate. Distinct from existing models of EU governance, it presents a challenge for health policy-makers and raises the question of a second ‘governance turn’ in EU studies. This post seeks to characterise the ‘third era’ of EU governance and its implications for health policy and broader EU analysis.

‘First era’ EU governance is characterised by the community method of policy-making and the development of the regulatory state. Grounded in its firm mandate for the establishment of the internal market and the promotion of free movement, the EU engages in ‘low politics’ sectors and initiatives to establish a comprehensive web of legislation and regulation governing the single market. This model dominated the EU’s formative years, until the emergence of the new modes of governance (NMGs) in the late 1990s. The introduction of the open method of coordination (OMC) and its institutionalisation in the Lisbon Treaty sparked an explosion of research on ‘second era’ EU governance and the ‘governance turn’ is now understood as a crucial marker in the history of both the EU and the field of academic studies dedicated to analysing its evolution (Kohler-Koch and Rittberger, 2006). The NMGs are characterised by a bridging of the EU’s constitutional asymmetry, allowing activity, coordination and cooperation in areas of social policy where EU competence is weak, as well as those economic policy areas which enjoy a strong legal mandate. In line with the weak competence afforded to them, the areas targeted are relatively sensitive and constitute ‘high politics’, encompassing employment, health, social inclusion and pensions. However, the soft law produced by the NMGs has been argued to hold significant potential for changing behaviour and institutionalising common practice without direct harmonisation (Greer and Vanhercke, 2010; Trubek and Trubek, 2005). As such, second era governance has presented a parallel but separate path of integration for social policy, establishing it as a kind of satellite, orbiting the narrowed Lisbon focus on growth and employment (Armstrong, Begg and Zeitin, 2008).

Responding to the economic crisis and the weaknesses revealed in the structure of Economic and Monetary Union (EMU), the EU has established a strengthened and expanded economic governance framework since the late 2000s. This third era framework defies almost all of the governance characterisations above. Whilst targeting areas of both high and low politics it is focused on something larger – a universal definition of ‘deeper and closer union’ has not been agreed but, in the minds of Monnet and Delors, it would almost certainly have involved collective discussion of national fiscal and structural policies, as embodied in the European Semester. Furthermore, the mandate to support EU action has been constructed as part of the process, with competence evolving to meet the needs made evident in the wake of the crisis and deemed to be in the common interest of member states. This has not resulted in minimal or weak powers, however – the EU now has the authority to sanction, in certain cases, governments which do not keep their debt and liabilities within strict limits. As such, third era EU governance is not an alternative to the previous two models (such as the ‘post-OMC’ model described by Sabel and Zeitlin, 2008), but rather imposes a level of upstream, ‘pre governance’; it sets standards, requirements and parameters which dictate and condition subsequent decision-making via the established frameworks. Administered in large part by economic and finance actors and excluding in large part national parliaments and civil society from meaningful participation, it poses a unique set of challenges to transparency, legitimacy and accountability, as illustrated by the health policy experience.

How then should EU governance 3.0 be approached? The ‘governance turn’ of the 1990s was revolutionary in that, whereas previous ‘integration studies’ had focused on the cause of cooperation between states, governance studies took the EU polity as a given and started looking at how it worked and what impact it had. The latest developments might indicate that it is time to take the workings and impact of EU governance as a given and start looking at how these characteristics and models are changing and can be changed to produce different visions of the EU. A constant set of micro-level EU policy dynamics, though not widely examined, is now acknowledged by most of the literature, suggesting that EU governance is now understood as an established feature of the EU polity. Most are agreed that this governance is multi-level, that there is a central set of actors which tend to behave in certain ways and that this behaviour and preference-set is determined by the system in which they operate. Defining, characterising and analysing the latest evolution of EU governance requires taking this framework a step further to examine the transformative nature of hard and soft law, the constraints imposed by perceptions of legitimacy, democracy and participation and the boundaries between macroeconomic and other policy areas vis-à-vis principles such as mainstreaming and Health in All Policies (HiAP).

Armstrong, Begg and Zeitlin (2008) ‘JCMS Symposium: EU governance after Lisbon’ Journal of Common Market Studies Volume 46(2).

Greer and Vanhercke (2010) ‘The hard politics of soft law: the case of health’ in Mossialos et al. (eds) Health systems governance in Europe (Cambridge University Press).

Kohler-Koch and Rittberger (2006) ‘The ‘governance turn’ in EU studies’ Journal of Common Market Studies Volume 44.

Sabel and Zeitlin (2008) ‘Learning from difference: the new architecture of experimentalist governance in the EU’ European Law Journal Volume 14(3).

Trubek and Trubek (2005) ‘Hard and soft law in the construction of social Europe: the role of the open method of coordination’ European Law Journal Volume 11(3).



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