The Europeanizationof Health Policy

Monika STEFFEN

Institute for Political StudiesUniversity of Grenoble (France)

Fiocruz / ENSP, Rio de Janeiro27th October 2010

Crossing complex concepts and realities

• There are different conceptions of what is :– Europe: geographic, cultural, political– Europeanization: from 6 to 25 Member States (MS)– Health policy: a field without frontier

• The twofold dilemma: – Exclusively national competency versus growing EU

involvement and impact – Social solidarity systems versus market and

competition requirements

Europeanization ?• Fashionable concept, concept stretching• Underlying hypothesis: harmonization, convergence,

policy transfer• Conceptualizations:– Institution building (now agencies)– Top-down (“Brussels” dictates, hard law)– Bottom-up (lobbying, MS governments included)– Both interwoven (mutual process of influence)– Euro-compatibility of national policy (negativeintegr)– Learning (norms, epistemic communities, soft law)– Nouvelle opportunities for national policy making (defreeze

conservative policymaking)

DIFFERENT DIMENSIONS OF HEALTH POLICY

1. Medical care system: service delivery, professionals2.Financing, social security provision for illness3. Public health and prevention (tobacco, alcohol, STD…): direct goal4. Policies with health impact (agrifood, environment…): indirect goal5. Health industries (pharma, medical equipment): employment, export

THREE different fields for EU policy, politics and law

• Healthcare systems: part of national social Security systems, organization and funding is exclusively NATIONAL competency

• Public health: national, international and growingly EU competency

• Medical products: fall under EU regulatory competency and EU competition law

Embeddedness of Health: …. in 25 Member States

Cultural context

Policy decision

Complementary approachesto “EU health policy”

• Historial development (EU literature)• Legal approach (E. Mossialos, T. Hervey)• Institutional approach (EU literature)• Political approach (S. Greer)• Identifying founding events (opportunity

window, accidental logic)

Historical landmarks • 1957 Rome Treaty: Transportability of Social Security

Reinforced 1971+72• 1975 Mutual recognition of diplomas: « White

Europe »• 1980s public health crises: AIDS, plasma, mad cows• 1993 Maastricht treaty : free open market, competition

– Common safety standards for medical goods, medicines, food– Free market for insurances: private (complementary) medical

insurance. What with compulsory health insurance ?

• 1990s – 2000s :– Fall of communism: transborder public health issues– Eastern Enlargement: access and quality of care

Institutional landmarks

• Les institutions concerned : – Commission – Court de Justice – Parliament– Council of the EU– Council of (health) ministers: networks, civil society

• Competency :– national : organization et finance of health care– Union : public health, prevention, transnational issues, and

« euro-compatibility » of care systems and finance

M. Steffen - M2 PPS 2010 10

The easy part, Public Health:Institutionalization

• Maastricht Treaty (1993): Art.129 “high level of health”

• Amsterdam Treaty (2000) modifies Art 129, now Art 152 : public health dimension in all EU policies. EU “completes” national action.

• New agencies as policy tools : EMEA 1993, EMCDDA 1993, EFSA 2003, EDCC 2004

• European Public Health Programs: Cancer, Aids, transmittable disease (Aids, VH, res.TB)

Internal distribution of competency

• GD Social Affairs : traditionally in charge of health as part of social security, mobility of professionals, transportability of rights. Now:– Open method Coordination (OMC)– Electronic European HI-Carte.– Patients’ mobility issue....

• GD SANCO (Santé and Consumer Protection): created 1997, reinforced with Amsterdam treaty. « Food safety », center of intense networking

• DG Industry and Rechearch:e-medecin, research funding, intense networking

The complicated part

• EU mainstream policy: the 4 freedoms – Free movement for people, goods, capital and

services. And free concurrence.

• The meaning for Health:– Mobility of patients, health professionals and

workers, – No public monopoly, no public subsidies, open

competition for tendering – Working time directive

The main issues

• I – Patient’s mobility• ECJ court decision• Home institution has to pay• Free will for ambulatory, goods, urgency• Prior authorization for non-urgent hospital care• Countries are opposed: limits their regulatory

capacity • Little real impact. Now promoted as “safety issue”

and “rights and protection of patients”

II -Public health insurance

• All insurance are “in principle under the competition law, but…”

• High political and public opposition in MS• ECJ rulings define exclusion:• Compulsory, solidarity, defined as: no link between

risk and premium paid, no link between contribution and service benefit

• No economic but clearly social goal• Regulation of private complementary Health

insurance to avoid cream skimming

III - Service directive

• Decision : health services are part of services, under competition law and free market

• General problem: regulation from country of origin would apply to services delivered elsewhere. (Bolkenstein–crisis),

• France fought for the general recognition of “services of general interest”, e.g. public services.

• Each country could dress it’s list of “exceptions”, few do because no change possible

• Health was taken out of the service directive in 2008

IV–What activity is subject to competition ?

• A) Recent developments: decision according to the precise “activities”, and part of activity (not public or private type of organization)– To avoid cream-scimming, and strengthen the

economic viability of public services• B) Decentralized application of European Law.– To avoid MS opposition and apply the traditional

principle of subsidiary.

Explaining the puzzle

• UE health competency : weakly treaty based, multiple ways, growing impact, hard and soft law

• Three distinct sources with cumulating effects :– Public health crises– Market integration and compliance– Policy discourse, diffusion of norms

• The Europeanization process is incremental and issue specific, thus often accidental, but logical

• UE holds a “general” policy mandate, member states a “specific" mandate

Questions

• What are the lessons for BIG federal countries like Brazil ?

• For other Regional unions, like MERCASUD ?

Further reading: Scott GREER, Tamara HERVEY, Elias MOSSIALOS