2021/09/01 by Rebecca Forman, Elias Mossialos, Elías Mossialos · 12 citations
Social Sciences · Business, Management and Accounting · Health Professions · #Global Security and Public Health #Global Public Health Policies and Epidemiology #Health and Conflict Studies
paper · pdf · doi:10.1111/jcms.13259
Like every region in the world, the EU struggled in its response to COVID-19 – particularly in 2020 when much was still unknown about the disease. The Global Health Security Index ranked several European Union (EU) countries – the Netherlands, Sweden, Denmark, Finland, France, Germany and Spain – among the 15 countries with the highest health security capabilities to respond to infectious disease outbreaks (Nuclear Threat Initiative and Johns Hopkins Bloomberg School of Public Health, 2019). Similarly, much of Western Europe received the best scores on the Epidemic Preparedness Index published early in 2019 (Oppenheim et al., 2019). But just a few months into 2020 it was clear these index predictions were wrong. COVID-19 policy making has involved significant uncertainties – about the nature of the disease, its transmission, and behavioural responses – and our understanding of the current and past trajectory of the pandemic has been limited by this (Manski, 2020). Thus, the EU was not alone in facing challenging choices. Even before COVID-19 hit, it was widely acknowledged that the world was underprepared. But many assumed that given the resources at its disposal, the EU would be better equipped to fight infectious outbreaks. After all, it is home to some of the highest performing health systems and scientific institutions in the world. Additionally, several institutions designed to support collective European response to communicable diseases were well established before COVID-19. However, there was limited consideration of globalization, geography and governance in the abovementioned measures – including gaps in analysis of regional and international organizations and the need to coordinate efforts between sub-national, national and global entities (Baum et al., 2021). Additionally, predictions about Europe's health security capabilities made the flawed assumption that just because European intergovernmental institutions were established, they had decision-making power, authority and adequate financing, they served the entire European region, and they had strong coordination with national and local-level efforts within countries. This was a significant oversight for the EU, where countries are highly interdependent and where healthcare systems and associated decision-making power lies with national governments rather than international policy bodies. As of 2017, 19 of the 25 most connected countries in the world and five of the world's 20 busiest airports were in Europe (Pan-European Commission on Health and Sustainable Development, 2021). Thus, an infectious agent emerging anywhere in the world can quickly pass into Europe and become a threat, and vice versa. Additionally, while Europe's global connectivity is a strength in many ways, disruptions in global trade and supply chains can prove catastrophic because of its interdependent nature. In this paper, instead of focusing on the individual national strategies that were so often split across Europe (Dergiades et al., 2020), we examine how the EU responded to the COVID-19 crisis and the interplay between the EU and its member states. Throughout, we consider the legal, institutional and political restrictions that may have influenced the boundaries of EU policy decisions. We begin with a background on the constraints on EU health (care) policy and then describe how these led to a series of knee-jerk reactions in initial COVID-19 management efforts which were exacerbated by the rise of nationalism among and lack of coordination between Member States. We then discuss how this was followed by elements of more strategic decision-making with the refinement of vaccination policies, the announcement of a new European health emergencies response agency and considerations on how to expand and strengthen infectious disease control at the European level. Finally, we conclude with suggestions on how the EU can continue taking strategic approaches towards pandemic planning and response, including through globally collaborative mechanisms and efforts. Health policy in the EU has a fundamental contradiction at its core (Mossialos and McKee, 2002). On the one hand, the Treaty on the Functioning of the EU (TFEU), as the definitive statement on the scope of EU law, states explicitly that healthcare is the responsibility of the Member States (Official Journal of the European Union, 2012. †). On the other hand, Member State health systems involve interactions with people (patients and staff), goods (pharmaceuticals and devices) and services, which are all granted freedom of movement across borders by the same Treaty. Furthermore, many national health activities are in fact subject to EU law and policy. EU health policies are influenced by what Scharpf terms the ‘constitutional asymmetry’ between EU policies to promote market efficiency and those to promote social protection (Scharpf, 2002; Permanand and Mossialos, 2005). The EU has a strong regulatory role in respect of the former, but weak redistributive powers as requisite for the latter. The asymmetry can be ascribed to the Member States' interest in developing a common market while seeking to retain social policy at the national level. However, while welfare and solidarity remain national-level prerogatives, many issues affecting the daily life and collective prosperity of individuals are dependent on EU-level actions (Tsoukalis, 2005). In the health arena, we see that the asymmetry is exacerbated by a dissonance between the Commission's policy-initiating role in respect of single market free movement concerns and the Member States' right to set their own social priorities. As a result, health policy in the EU has, in large part, evolved within the context of the economic aims of the single market programme (McKee et al., 1996; Wismar et al., 2002). This has led to a situation in which the Member States have conceded the need for the EU to play a role in health, even if only a limited one, and in ill-defined circumstances. Furthermore, since the 1992 Maastricht Treaty, the EU has been required to ‘contribute to the attainment of a high level of health protection’ for its citizens. This is an understandable and important objective in its own right, and there is compelling evidence that access to timely and effective healthcare makes an important contribution to overall population health. But, notwithstanding the EU's commitment to various important public health programmes and initiatives, how are EU policymakers to pursue this goal of a high level of health attainment when they lack Treaty-based competences to ensure that national health systems are providing effective care to their populations? This is in stark contrast to environmental protection, an area of EU policy where the EU is given explicit competence over measures affecting water resources, land use (with the exception of waste management) and energy choices and supplies under Title XX of the TFEU (Consolidated versions of the Treaty on European Union and the Treaty on the Functioning of the European Union, 2012). This is not to equate health and social policy with environmental policy; rather, it simply highlights that a greater policy mandate for areas outside (though related to) the single market could be accorded to the EU via the Treaties if desired, and that the asymmetry need not be as clear or as limiting as it appears to be for health. This suggests a redefinition or, at least, a reorganization and re-prioritization of health at the EU level is needed. Before considering the initial COVID-19 response, we must take stock of the legal framework in which these institutions were situated, and the governance challenges posed by transboundary health threats. While health policy in the EU is dominated by national policies, some transboundary emergency response capabilities have increasingly been delegated to EU bodies in the last decade (Schomaker et al., 2021). Article 168 of the TFEU, referring to ‘normal’ non-emergency situations, stipulates that a ‘high level of human health protection shall be ensured in the definition and implementation of all Union policies and activities’ (Consolidated versions of the Treaty on European Union and the Treaty on the Functioning of the European Union, 2012). EU actions could include ‘monitoring, early warning of and combating serious cross-border threats to health’. The European Commission (EC) was responsible for the initial COVID-19 responses mainly through the Directorate-General for Health and Food Safety (DG-SANTE) which has a broad scope to protect public health and build a strong European Health Union and the Directorate-General for Research and Innovation (DG-RTD) which coordinates and allocates funding towards health research and innovation – including preparedness for pandemics through the research and development (R&D) of medical countermeasures and diagnostics. EU agencies involved in the management of the crisis included the European Centre for Disease Control (ECDC) (Regulation (EC) No 851/2004, 2004) which aims to strengthen the European defence to infectious diseases through the identification, assessment, and communication of current and emerging infectious threats to human health and the European Medicines Agency (EMA), which works to ‘foster scientific excellence in the evaluation and supervision of medicines, for the benefit of public and animal health in the EU’ (European Medicines Agency, 2020). The EU Civil Protection Mechanism which was established to boost cooperation on civil protection matters and improve prevention, preparedness and response efforts for environmental emergencies and disasters also played an important role in managing COVID-19. The mechanism includes the Emergency Response Coordination Centre (ERCC) responsible for coordinating assistance to countries (both inside and outside the EU) affected by disasters as well as rescEU, responsible for enhancing the protection of EU citizens from disasters and managing emerging risks, mainly through reserves of resources and stockpiles of medical equipment. Furthermore the Health Security Committee (HCS), based in DG-SANTE and the Early Warning and Response System (EWRS) hosted by the ECDC, granted the EU some additional capacity to coordinate policy responses (Decision No 1082/2013/EU, 2013). Thus, going into the COVID-19 crisis there was an institutional and legal basis for the EU to operate; albeit other policy areas, such as humanitarian aid, had a much larger remit and more organizations supporting them in crisis responses (Schomaker et al., 2021). In the first months of 2020, much of the bloc was conducting business as usual and failed to take threats of the virus seriously. From as early as January 2020, the Commission sounded the alarm on the novel coronavirus and called for coordinated responses. But without the buy-in of all member states, its influence was severely limited. By the time attention shifted towards the virus, it was far too late: at the end of the first quarter, COVID-19 had spread to most countries in Europe and forced decision-makers to take knee-jerk reactions in policy response. On 9 January 2020, DG-SANTE opened an alert notification through the ECDC's EWRS and the ECDC released a Threat Assessment Brief which reported that a novel coronavirus had been the causative agent for 15 of 59 cases of pneumonia in Wuhan, China (European Centre for Disease Prevention and Control, 2020a). Soon after, the ECDC published a rapid risk assessment and the EU held its first coronavirus-related conference call on 17 January to discuss measures to prevent the virus from entering Europe. However, only 12 of the 27 member states (and the UK) attended the call (Boffey et al., 2020), and those who did about the in – for measures in of was about the its of and and many made the flawed assumption that this was outbreaks and would to borders with the in On January the ECDC its rapid risk assessment from to of to countries (European Centre for Disease Prevention and Control, 2021). the first cases of COVID-19 in and Germany on and January The EU Civil Protection Mechanism was for the of EU citizens on January (European and by the the of what is called a public health emergency of international into and on the ECDC published a on the need for in healthcare in of an in infectious Additionally, on the ECDC released for to and the of the (European Centre for Disease Prevention and Control, 2021). the many EU did not consider the of the virus to be serious to or to and were at the and to be by who also did not the of the COVID-19 But by of COVID-19 cases in of had and individual cases to across European countries. On 2020, established a response at the political but the virus was Europe (European In 2020, as the of the the has the of for the of medicines, and via the EU et al., 2021). DG-SANTE national with and policies, but it is the responsibility of and governments to the and policies that DG-SANTE on public health (European While through the ECDC, the alarm on the novel coronavirus on 9 January 2020, COVID-19 quickly the of these in its the ECDC did not have remit the Furthermore, the ECDC was severely limited by its human and capacity at the of the pandemic and Mossialos, 2020). Additionally, the could only scientific which its authority to This is not to that the ECDC did not to early COVID-19 response efforts. After the of a of in the ECDC attended at the of the pandemic to and best with the Union, and (European of 2021). also established a COVID-19 which on a published a COVID-19 and COVID-19 through the EWRS and European System (European Centre for Disease Prevention and Control, However, the between member and of and the limited remit and powers of the ECDC significant challenges in managing the of the COVID-19 In to the of the ECDC, the European response was by by Member States to resources for their own rather than these Europe based on need et al., 2020). a European on 2020 where solidarity and cooperation and transmission, and providing medical for the of several European countries quickly on when were et al., 2020). the pandemic first hosted a of resources from member states that could be in of emergency than the resources and was to a situation where member states were with the same emergency and in need of the same supplies et al., 2021). This to access to for their medical and In to these in the first of 2020 the Commission to strengthen and the by providing more funding and more across member states (European a strategic medical and has been established with the hosted by EU member states. Furthermore, the legal of cross-border efforts to infectious outbreaks were This was by which just as the virus was to the Additionally, there was not adequate for at this in the pandemic – in 2020, only had been to 17 were to efforts to economic of COVID-19 to health and et al., 2020). The early in the pandemic response to a what some member states which in intergovernmental and to common et al., 2021). Early in 2020, in response to the virus, the EU established a Coordination sounded the alarm on COVID-19 on January and in the same to strengthen healthcare capacity in of the But and most public attention within Europe on the (Boffey et al., 2020). of and lack of other international was on 25 the for Europe called for the region to for the virus and as 2020), but at this most member states failed to to these and their stockpiles of to for an of infectious in health and care and to begin such as social and This led to the situation in when and countries were were and systems were so the of After such a clear of solidarity was in Europe in the of 2020, and as to Member States' shifted and support for an to But even this was governments were in about the they and by the time they global were limited. in the to countries and additional for it early for the first of to be under the (Boffey et al., 2020). it that the was the European Commission emergency that for a through – in the of initial responses (European By this for more decision-making power to European institutions in of crisis was By the of 2020, scientific had been made in the development of COVID-19 In 2020, there were several and a few COVID-19 were and in of the world by the end of the – in the from with COVID-19 in the first of 2020, challenges with in the of the and into In 2020, Member States the European Commission (European which included a mechanism they would the and lack of solidarity in Europe that was with early in the While may have been a in the was with such a and rather than it as an emergency for it for over for By the had a to supply its entire population with one and for its population to a Similarly, on 20 the a them of a COVID-19 and 2021). The EU did not its first by which the and the had from to their entire more than while the EU may have a better on there were in early and and while to Europe they in countries which had in their and 2021). This quickly set the EU far countries such as the and the in the of its of coordination and communication also early vaccination efforts. On 2020, the was the first to a COVID-19 2020). The and followed The the regulatory agency – the – for in its and that the was more 2020). However, the emergency for the same with to that of the the is not responsible for these and efforts to improve between these bodies is from all The current lack of international coordination only to more challenges and as the pandemic response for which of evidence is as borders for While the makes to the the about use of with Member State This led to across the EU countries in which were made who was and to and the between first and Even before were high of in several countries in the bloc 2020). The and in policies the EU and globally for about the and of the – particularly with to et al., 2021). the gaps in COVID-19 in 2020, and to prevent from in the in 2020, the that a new EU Health Emergency Preparedness and Response to as would be established (European The scope of the agency has not been or but it is to be to the Research and and its broad include the for health funding for medical supporting and medical supplies and et al., 2021). the of the re-prioritization of health at the EU level and the of the to to a more to its member health systems of a for emergency preparedness planning and response in Europe. Thus, its and not only its but also on how it within this and with agencies and institutions to build EU capacity to respond and from health rather than simply the et al., and 2021). could play a coordination it has the to coordinate development to support to in with the to coordinate various funding programmes for health across the bloc – with to coordinate with DG-SANTE to support the of medical to coordinate with the EU Civil Protection Mechanism to the of the goods in these and to coordinate with international and to international such as the COVID-19 Global et al., 2021). This may be than and its early be dependent on clear of its its with and its is also an to strengthen European infectious disease The ECDC was established in in the of the in with the to boost the European defence to infectious diseases through the identification, assessment and communication of current and emerging infectious threats to human health. has several coordination mechanisms for disease response, with the and an early warning and response that countries and them to quickly and However, the ECDC has from a of issues including limited scope and that have severely its to its and Mossialos, 2020). This was in the early of the pandemic when the ECDC's remit was mainly limited to and coordinating with national public health agencies on efforts. in funding to the programme may a to additional funding into the ECDC and expand its role to and with countries to (European 2021). could also to planning efforts and by coordinating and programmes to infectious disease and and Mossialos, 2020). However, an role of the ECDC would to and of its such as and the nature of mechanisms may need to be and Mossialos, 2020). the of and the role of the ECDC, there is still a of to and to in this and in better for the The EU and member states must from their with COVID-19 et al., and efforts to strengthen the capacity of its institutions to respond to and from health threats. In a to the EU vaccination Europe its and is to and even and vaccination by the end of 2021). Early in supply and and on the of cases of Europe on its But by Europe was a with and for over of their to the EU by 2021). even while it struggled to its own the EU and the with of in 2020 and early This but there are still many important challenges which need to be to improve pandemic preparedness and response in Europe. in social and could better predictions of when and how infectious disease threats in the The development of mechanisms to and entire could countermeasures and and response to outbreaks. and behavioural could also be made to prevent the risk of and spread of to or at early and to the of on infectious disease response. Furthermore, challenges related to health and healthcare can be and and policies of and healthcare and better preparedness to and respond (and to the pandemic may be and these challenges and need for the EU an pandemic response for Europe which the strategic of and the interactions between EU Member as well as international organizations such as the Health The EU must also take a Health et al., in its in of and for the threats of and (Pan-European Commission on Health and Sustainable Development, 2021). we that European health is not just dependent on national health but also on economic and global governance systems (Pan-European Commission on Health and Sustainable Development, 2021). is that the EU also works at the of global planning efforts. are global by and they international responses which are coordinated and The EU continue in its towards and support of a Treaty which and for states to to under pandemic taking stock of what has and has not with and the Health (Pan-European Commission on Health and Sustainable Development, 2021). Additionally, the EU not only continue efforts to boost its own COVID-19 vaccination but it can also play a role in the development of a Global for This global policy set the and of all those involved in the and and it innovation while also that high of protection are under pandemic (Pan-European Commission on Health and Sustainable Development, 2021). The asymmetry in the EU healthcare policy has exacerbated challenges in the first of the COVID-19 crisis and going the EU must from these and take an increasingly role in efforts to with cross-border threats to health. This to the TFEU that the EU under circumstances. While this may have been among Member States in the the for it has since the COVID-19 crisis has the of European coordination and solidarity in cross-border emergency responses.