Sunday, 8 September 2013

Economic governance for European health

Governance for (global) health starts at the national level. This concept is elaborated by the WHO in its publication Governance for health in the 21st century. The new governance for health is strongly rooted in concepts like Health in all Policies, multi-stakeholder approaches and democratic decision making for health. But aren’t we fooling ourselves with these trendy approaches? In a sense political philosopher Antonio Gramsci already promoted this governance model when he wrote about an ‘extended state’ that consists of media, civil organizations and labor unions exerting their influence on policy makers and politicians. Extended state actors are crucial in shaping the ‘cultural hegemony’, the social, cultural and political values, that shape society and state governments.  To be clear, the cultural hegemony is not something that emerges by consensus. No, it is shaped by political thinking, debate and ‘sometimes’ bitter fights.

And this is where the comparison between  ‘depoliticized’ multi-stakeholder approaches and Gramsci’s concept of a ‘political society’ diverges. Do the new governance for health and health-in-all-policies concepts allow for the strengthening of political societies for health or is its ‘the-world-is-flat” notion merely a form of dominant hegemonic leadership?

I wonder what Antonio Gramsci would have thought of current governance for health at the European level. Last week, the European state of public health was discussed at the 4th annual conference of the European Public Health Alliance. The title’ Brave new world, inclusive growth and well-being or vested interests and lost generations’ describes perfectly what is at stake. The first day (with an impressive line-up of presenters) focused mainly on health systems reform in European member states, protecting access to services during austerity measures, addressing inefficiencies in health systems, and at the same time investing in sustainable long term (public) health programs. It is the second day that I like to highlight, as here the impact of the current EU economic framework for health has been discussed. This reform of the European economic governance, part of the EU 2020 growth strategy and also known as the European semester, has a thorough and structural impact on public health and health care in all member states. The entire process and mechanisms of this new economic framework and EU macro-economic surveillance can be found in this excellent EPHA briefing from April 2013.

Alongside this European semester, a number of countries (Greece, Portugal, Spain, Ireland) receive financial assistance (bailout funding) from the Troika (being the European Commission, European Central Bank and International Monetary Fund). These countries are subject to specific reforms of their public expenditure and fiscal frameworks. This is typically done under an MoU between a countries government and the Troika. The (first) effects of the economic crisis and related austerity measures on public health outcomes in these and other European countries has been presented in in the Lancet earlier this year, as well as by WHO EURO.

Rita Baeten from the European Social Observatory explained during the conference clearly how the EU macro-economic surveillance has profound impact on the development of national health care systems, without Ministries of Health being involved so far!  It is eventually the European ministries of finance, that within the Economic and Financial affairs (ECOFIN) council ‘recommend’ on the macro-economic structural reforms and fiscal consolidation of countries state budgets. Each year in November an Annual Growth Survey (AGS) is published that gives general guidance for EU member states for measures to ‘ensure financial stability, fiscal consolidation and action to foster growth’. Regarding health care the AGS 2013 mentions “reforms of health care systems should be undertaken to ensure cost-effectiveness and sustainability, assessing the performance of these systems against the twin aim of a more efficient use of public resources and access to high quality healthcare.” Although there is mention that social protection systems should be protected and strengthened, there is no reference to (health) inequalities. Seemingly the principle of reducing social inequalities has to be sacrificed in the times of financial crisis.  

Since 2011 the EC and Council produce Country Specific Recommendations (CSR) on macro-economic sustainability. In 2013, 16 CRS have been made. E.g. for the Netherlands, related to its health system, the following recommendation was made: “Implement the planned reform of the long-term care system to ensure its cost-effectiveness and complement it with further measures to contain the increase in costs, with a view to ensure sustainability. While the plans entails substantial budgetary savings, additional measures are likely to be necessary to fully restore the long-term sustainability of public finances.” An overview of the CSRs and its relation to health can be found in this EPHA policy analysis from Sept. 2013.
So, some key questions can be asked about the governance of the European Semester in relation to health:
  • What is the legitimacy of Ministers of Finance to “strongly recommend” on the content and reform of the health system at national levels?
  • Is the treaty of Europe not breached here; as health systems ought to be under national competency and responsibility of member states, not that of the EU. The treaty on the functioning of the European Union mentions in article 168 the responsibilities of the member states and the EU in protecting and improving public health.
  • There seems hence to be a contradiction between different EU policies “fostering sustainable growth” and creating “social cohesion and protection”.
  • The transparency of the process is unclear. Where do these recommendations come from? It seems mainly from the EC, probably influenced by the thousands of corporate lobbyists in Brussels, in addition to a selected group of people in and around the ECOFIN council (in which the EUROGROUP is currently chaired by the Dutch Minister of Finance). The European Parliament, national ministers of social and health affairs and civil society groups have had so far little influence in its directions. Partly because the EU economic framework evolves with fast changing targets. Especially the fact that the European Parliament has so little power in relation to the European Semester indicates the “democratic deficit” existing in current Europe.

The European Public Health Alliance has since 2013 analyzed these developments and does it best to be engaged and influence this process. Other European bodies, such as the Social Protection Committee and the Employment, Social, Health and Consumers affairs (EPSCO) Council also have a role in co-legislating the AGS and CSR. More transparency by these bodies and involvement of civil society organizations has occurred, but impact so far has been negligible. Thorough coordination and cooperation between social movements is required as decisions take place both at national and European level. 

Rita Baeten made it clear in her final remarks: “The house of Europe is built on the basis of liberal economic principles such as fiscal consolidation, GDP growth, small public expenditures and an internal open market as to be competitive with other emerging economies”.  In times of economic crisis, we see the true face of the current European Union and its decision makers. It values its economic interests simply higher than social cohesion by and for European citizens (and those that live undocumented in the region).  Moreover, didn’t some economist say ”never let a good crisis go to waste”? We see an assault by those with commercial interests on our social systems, and, at the EU level, we lack the true democratic possibilities to address this. We must demand our national governments and health ministries not only to fulfill their responsibilities in public health and access to health care but also to reform the governance model of the EU, and challenges this structural democratic deficit. The current EC and EU structures favor economic goals over societies’ goals.  How much longer will the European people accept this? The current European cultural hegemony is in crisis. Is there enough mass for an alternative hegemony?

Remco van de Pas, Wemos foundation

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