Healthcare workforce and EU health governance

TOPIC, THEME, ISSUE DESCRIPTION

This session might discuss challenges for healthcare workforce (HCW) planning, retention and fixation between national healthcare systems, and the impacts of the single market and free movement of goods and people in the EU.

IDEAS FOR ACTIVITIES, DISCUSSION QUESTIONS, ASSESSMENTS ETC.

The main activity would involve exploring current policy options and best practices undertaken by national healthcare systems and assessing their effectiveness towards the HCW goals. In what areas of EU law and Commission competences, could the EU act on harmonising HCW planning, retention and fixation between Member-States? Discussion and innovative approaches; do financial instruments and fiscal policy arena have scope to become effective strategies for managing HCW?

ANNOTATED READING LIST

Glinos, I.A. Health professional mobility in the European Union: Exploring the equity and efficiency of free movement. https://doi.org/10.1016/j.healthpol.2015.08.010.

The author argues that health professional mobility has efficiency and equity implications in the EU. They note that some EU Member States benefit more from health professional mobility, whilst free mobility of health professionals may reinforce intra-EU disparities.

The role of law in EU health governance

TOPIC, THEME, ISSUE DESCRIPTION

This session considers the EU law framework regarding issues of health governance in the EU. So it will consider not only the “cross-cutting” nature of EU health law (as a discipline), but also unpack some examples of how law works in this area, and where/how it interacts with policy.

IDEAS FOR ACTIVITIES, DISCUSSION QUESTIONS, ASSESSMENTS ETC.

Case studies / problem scenarios to work through, e.g., concerns about accessing healthcare from the perspective of EU citizenship rules, and considerations emerging in state aid assessments. Recent cases could form the basis for this, e.g.

• Casa Regina Apostolorum (CJEU 2023 judgment), regarding state aid to Italian public hospitals, offers opportunities to examine not only social/economic tensions in EU law as applied in the healthcare sector, but also the Member State – EU-level dynamic regarding healthcare system organisation, and how far the EU institutions may be willing to go in scrutinising national arrangements.
• Case C-247/20, VI v Commissioners for Her Majesty’s Revenue and Customs, (CJEU 2022 judgment) regarding the linking of the NHS with the requirement for comprehensive sickness insurance (CSI) for EU nationals in the UK. This case offers scope to consider how health (via CSI) is an integral part of free movement and citizenship rules, also raising questions of economic/social tensions and EU-level/Member State interaction.

Consideration of Health in All Policies (HiAP) could also be linked to discussions of the EU’s competence in health, and how law might be used to help reinforce policy.

ANNOTATED READING LIST

O. Bartlett and A. Naumann, ‘Reinterpreting the health in all policies obligation in Article 168 TFEU: the first step towards making enforcement a realistic prospect’, (2021) Health Economics, Policy and Law 16(1), 8-22.

• Discusses links between HiAP ‘in law’ (Art. 168(1) TFEU) and in policy.

A. de Ruijter, EU Health Law & Policy (OUP 2019).

• Discusses the EU’s expanding role in public health and healthcare from a values and rights perspective.

Hervey and McHale, European Union Health Law – Themes and Implications (CUP 2015).

• Comprehensive overview of the development and extent of EU health law. Discussed thematically in terms of “internal” EU health law (both individual and systemic perspectives) and “external” EU health law.

Hancher and Sauter, EU Competition and Internal Market Law in the Healthcare Sector (OUP 2012).

• Comprehensive overview of how competition and internal market law have been applied in health cases.

The European Health Union

TOPIC, THEME, ISSUE DESCRIPTION

This session addresses the emergence and possible development paths of the European Health Union (EHU), its implications for the status of health policy within the EU institutional architecture, the role/competences of new agencies (e.g. HERA). Key question: to what extent has the pandemic been the ultimate crisis in order to advance the idea of an EHU?

IDEAS FOR ACTIVITIES, DISCUSSION QUESTIONS, ASSESSMENTS ETC.

Activity: Analysing political statements with regard to the creation of a European Health Union (drawn from, for instance, the Commission President, parties within the European Parliament, member state leaders etc.). The task involves differentiating competing visions and driving forces of the EHU, assessing the EHU process through a supranationalism/intergovernmentalism lens; and predicting the possibility of EHU scenarios (e.g. further integration, differentiated integration, status quo).

ANNOTATED READING LIST

Nabbe, M.; Brand, H. The European Health Union: European Union’s Concern about Health for All. Concepts, Definition, and Scenarios. Healthcare 2021, 9, 1741. DOI: https://doi.org/10.3390/healthcare9121741

• The article identifies five potential scenarios of a European Health Union based on a scoping literature review. The suggested scenario plots, ranging from a full-fledged EHU (scenario 1) to a fragmentation of the EU (scenario 5), are discussed alongside three predetermined  forces (surveillance and monitoring, crisis preparedness, funding) and four unpredictable forces (political will, vision of public health expenditures, population interest and awareness, global health).

Kickbusch, I. and De Ruijter, A. (2021). How a European health union can strengthen global health. Commentary. The Lancet Regional Health Europe. DOI: https://doi.org/10.1016/j.lanepe.2021.100025

• Discusses the implications of the EHU for global health, offering an introduction to the EU’s role in global health and the idea of the EHU.

Far-right political parties and health in Europe

TOPIC, THEME, ISSUE DESCRIPTION

This session looks at far right political parties in Europe, their influence at EU and national levels, and their views on / implications for health. It contrasts the rise of such parties, the limits of their success in securing formal governance positions and the dearth of research into their relevance to health.

IDEAS FOR ACTIVITIES, DISCUSSION QUESTIONS, ASSESSMENTS ETC.

Activity: analysing political manifestos. Using manifestos from 2-3 far-right parties in different European countries (language barriers permitting), analyse these parties’ position on health, using a framework that explores reference to individual versus social drivers of health inequalities. Can be done individually or in groups, in-person or online (in breakout rooms, for instance).

ANNOTATED READING LIST

Falkenbach and Greer (eds) (2019) The Populist Radical Right and Health (Springer).

This is an edited volume, the first in-depth analysis of the health policies of populist radical right parties. Its scope is global but more than half of the case study chapters are based in EU member states (and their division by country makes for easy group-reading activities).

The EU and global health

TOPIC, THEME, ISSUE DESCRIPTION

This session considers the EU as a global health actor/non-actor, EU soft power through health and health diplomacy, and the EU’s role in global health security.

This session also facilitates debates and reflection on who, how, and why global health is governed. Subthematics include global health leadership, health in global governance, and the interaction of the EU with other global health actors such as the WHO, the World Bank, the Global Fund, and GAVI, among others.

IDEAS FOR ACTIVITIES, DISCUSSION QUESTIONS, ASSESSMENTS ETC.

Task: analyse the role of the EU in global health equity through the COVID vaccine case study. Drawing on selected readings, media reporting and blogs, use the EU’s role in COVID vaccine procurement and distribution to assess its contribution to global health equity. Students may need to be introduced to a health equity framework/lens (or may have used this earlier in the course/other courses).

Furthermore, students are encouraged to analyse EU health agencies’ role and impact on global health activities by interpreting agencies’ functioning data (finances, governance, procurement, and transparency). This will be done by reading selected material, extracting information from agencies’ websites, and contrasting it with multiple sources.

ANNOTATED READING LIST

Bergner (2023) The role of the European Union in global health: The EU’s self-perception(s) within the COVID-19 pandemic, Health Policy, 127, 5-11.

• Analyses the EU’s role in global health, via the COVID pandemic, along the dimensions of self-perception, external perception and performance.

Usher, A.D., (2021). A beautiful idea: how COVAX has fallen short. The Lancet, 397(10292), 2322-2325.

• A shorter article introducing the COVAX facility and the shortfalls in equity during its operation.

Bengtsson, L. & Rhinard, M., 2019. ‘Securitisation across borders: the case of ‘health security’ cooperation in the European Union’, West European Politics, 42(2), 346–368, DOI: https://doi.org/10.1080/01402382.2018.1510198.

Bengtsson, L., Borg, S. & Rhinard, M., 2019. ‘Assembling European Health Security: Epidemic intelligence and the hunt for cross-border health threats’, Security Dialogue, 50(2), 115–130, DOI: https://doi.org/10.1177/0967010618813063.

Sonja Kittelsen (2007) Beyond Bounded Space: Europe, Security, and the Global Circulation of Infectious Disease, European Security, 16:2, 121-142, DOI: 10.1080/09662830701529745

Thibaud Deruelle & Isabelle Engeli (2021) The COVID-19 crisis and the rise of the European Centre for Disease Prevention and Control (ECDC), West European Politics, 44:5-6, 1376-1400, DOI: 10.1080/01402382.2021.1930426.

DIJKSTRA, H., & DE RUIJTER, A. (2017). The Health-Security Nexus and the European Union: Toward a Research Agenda. European Journal of Risk Regulation, 8(4), 613-625. doi:10.1017/err.2017.34.

Dodgson R, Lee K, Drager N. Global Health Governance, A Conceptual Review. Glob Heal. 2018;(1):439–61.

Clinton C, Sridhar DL. Governing global health: who runs the world and why? 2017. 282 p.

Gostin LO, Mok EA. Grand challenges in global health governance [Internet]. Vol. 90, British Medical Bulletin. Oxford Academic; 2009 Available from: https://academic.oup.com/bmb/article-lookup/doi/10.1093/bmb/ldp014.

Andrews M. The good governance agenda: Beyond indicators without theory. Oxford Dev Stud. 2008;36(4).

Besley T, Kudamatsu M, Merlo A, Olken B, Nunn N. Health and democracy. In: American Economic Review. 2006.

Kevany, Sebastian, and Aoife Kirk. Outbreaks, Epidemics, and Health Security: COVID-19 and Ensuring Future Pandemic Preparedness in Ireland and the World. San Diego: Elsevier Science & Technology, 2022. Print.

Democratic legitimacy, healthcare and EU health governance

TOPIC, THEME, ISSUE DESCRIPTION

This is a reflective session which focuses on how EU competences affect health. Should the EU have more explicitly health-related competences, or should this remain with Member States? What are the implications of either option?

IDEAS FOR ACTIVITIES, DISCUSSION QUESTIONS, ASSESSMENTS ETC.

Activity: Think about the ‘pros/cons’ of more health competencies, perhaps structured across the ‘three faces’ of EU health policy, or the WHO building blocks of health systems. Ideas could be devised individually, then compare findings in pairs, then create groups of 4 (‘pair up the pairs’) and exchange findings until students have an overview of the implications and issues at stake.

ANNOTATED READING LIST

Greer, S.L.,(2014). The three faces of European Union health policy: Policy, markets, and austerity. Policy and Society, 33(1), 13-24.

• One option to structure the task is to think about the implications of competences across the three faces of health policy.

Greer et al. (2022) Everything you’ve always wanted to know about EU health policy but were afraid to ask, https://apps.who.int/iris/handle/10665/354182.

• A more comprehensive overview/introduction to EU health policies and competences.

Lamping, W., & Steffen, M. (2009). European Union and Health Policy: The “Chaordic” dynamics of integration. Social Science Quarterly, 90(5), 1361– 1379.

• Slightly older source but one that reflects on the limits and value of EU health integration.

Public policy and the determinants of health

TOPIC, THEME, ISSUE DESCRIPTION

This session addresses how EU policy affects health even if it is not directly about healthcare/health systems. Potential case studies or focal points include health in all policies (HiAP); Better Regulation; the eurozone crisis, austerity, and health; food safety regulations and health; trade and Health; the CAP and health…

IDEAS FOR ACTIVITIES, DISCUSSION QUESTIONS, ASSESSMENTS ETC.

Activity: Creating maps of how the EU activities can indirectly impact health through other policy areas (such as food, environment, fiscal policy, trade, etc). This can be a really creative exercise, using paper and pens, whiteboard and markers, or online drawing software.

Discussion topic: Using the concept of ‘policy coherence’, students might reflect on their maps and consider the challenge of generating coherence across such a wide range of policy sectors and actors.

ANNOTATED READING LIST

Greer, S. L. (2014a). Three faces of European Union Health Policy: Policy, markets, and austerity. Policy and Society, 33(1), 13–24.

• Offering an initial overview of the three faces of health policy and the range of EU non-health competences and actions that affect health.

Karanikolos, M., Mladovsky, P., Cylus, J., Thomson, S., Basu, S., Stuckler, D., Mackenbach, J. P., McKee, M. (2013). Financial crisis, austerity, and health in Europe. The Lancet, 381(9874), 1323–1331.

• As a case study, this source introduces the impact of austerity on health in Europe following the financial crisis in 2007/8.

Koivusalo M (2010). The state of health in all policies (HiAP) in the European Union: potential and pitfalls. Journal of Epidemiology and Community Health, 64(6):500–3.

Jarman H & Koivusalo M (2017). Trade and health in the European Union, in Hervey TK, Young C & Bishop L (eds). Research Handbook on EU Health Law and Policy. Cheltenham: Edward Elgar Publishing, pp. 429–52.

The politics of European Union and health

TOPIC, THEME, ISSUE DESCRIPTION

The European Union (EU) has been engaged in health issues since the Thalidomide tragedy in the 1960s, which led to the introduction of the European pharmaceutical authorisation process. Since then, the EU’s role in health has been diversified and extended. The European Health Union initiative, which emerged as a response to the COVID-19 pandemic, is the most recent and ambitious attempt to establish a stronger role for the EU in health. In this context, this session addresses the following question: What should the EU’s role in health be? The session is designed to familiarise students with the normative and political debates on European integration in health, enable them to formulate and articulate their own stances in these debates and create a platform to foster an open dialogue on the appropriate role of the EU in health among students.

IDEAS FOR ACTIVITIES, DISCUSSION QUESTIONS, ASSESSMENTS ETC.

Activity: The proposed activity is to create a platform for students to form a political stance on the European Union’s role in health, consider different political alternatives and elaborate on their stances while interacting with their classmates. It is recommended that the instructor uses live polling methods to spark a debate. For this purpose, the instructor is expected to prepare different statements about the preferred division of responsibility between the European Union and its Member States in different sub-sectors of health (e.g., pharmaceutical reimbursement decision, EU-wide health tax). These statements can include both statements reflecting the current state of affairs and ones that are aspirational. For a one-hour session, 12 statements would be sufficient.

In terms of the session outline, the first step is that the instructor asks students to respond to each of these statements in an “agree and disagree format”. The instructor is advised to use the Vevox app, which allows live polling, and recording of student responses. Once students individually express their opinions on a statement in terms of agree and disagree through the app, it is recommended that the instructor first shows the overall results for the class. Then the instructor is expected to explain whether each statement reflects the current state of affairs. This is followed by a lively discussion on the appropriate role of the EU in the selected areas within health policy. When the discussion reaches saturation, the instructor should then outline the political dimensions of each statement and state that every opinion expressed deserves political respect. The same order can be repeated for each statement. This activity must be completed before delivering a lecture on the European Union’s involvement in health and the contemporary European Health Union initiative.

Discussion topic:

• The European Union should introduce a single European social health insurance plan with the same entitlements for all EU citizens.
• The European Union should levy a Europe-wide sugary drinks tax that will become a new revenue source to the EU budget.

ANNOTATED READING LIST

Bambra, C., Fox, D. and Scott-Samuel, A., 2005. Towards a politics of health. Health Promotion International, 20(2), pp.187-193.

Carpenter, D., 2012. Is health politics different?. Annual Review of Political Science, 15, pp.287-311.

Greer, S.L., Rozenblum, S., Fahy, N., Brooks, E., Jarman, H., de Ruijter, A., Palm, W. and Wismar, M., 2022. Everything you always wanted to know about European Union health policies but were afraid to ask. World Health Organization. Regional Office for Europe.