European support for improving global health systems and policies

The European Union (EU) is one of the world’s largest markets, aid donors, health care innovators and tradingpowers. As such, many of its policies affect global health. EU policies affect global health directly, as with overseas aid, trade policy or support for the World Health Organization (WHO). They also affect global health indirectly, as with the many internally focused policies which affect health and health policy options in other countries, such as research priorities or medicines regulation. The extensive range of policy areas that touch global health mean that the EU has a wide range of policy tools which inevitably shape global health, and which the EU can use intentionally to shape health governance and outcomes worldwide.The broad shape of any coherent strategy or approach to global health, in the complex institutional environment ofEurope, must align priorities with tools, identifying what the EU wants to achieve in the global health sphere andwhich policy tools will be best suited to have the desired effects. Alignment requires consideration of the differentways in which countries near the EU already relate to it (e.g. accession candidates) and should include anappreciation of which actors should use the different policy tools, with respect to subsidiarity as well as the advantages of joint action in some areas. The review of EU instruments clearly shows the immense scale of the impact of existing EU policies on global health, and the potential that a coherent approach could have to strengthen global health governance and improve global health policies and outcomes. The EU affects global health through many different policies; the question is how, when and by whom these policies will be used for global health.

Defining and analyzing health system resilience in rural jurisdictions.

Rural areas face well known and distinctive health care challenges that can limit their resilience in the face of health emergencies such as the COVID-19 pandemic. These include problems of sparsity and consequent limited health care provisioning; poverty, inequalities, and distinctive economic structures that limit access to health care; and underlying population health risks and inequalities that can increase vulnerability. Nonetheless, not all rural areas face the same problems, and non-rural areas can have challenges. To be useful in influencing policy, a tool to identify more and less resilient areas is necessary. This Commentary reviews key forms of risk and constructs a county-level index of resilience for the United States which helps to identify countries with limited resilience. Further, it argues that health care resilience should be conceptualized in terms of broader regions than counties since health care facilities' referral regions are larger than individual counties; resilience needs to be understood at that level. The index, read at the level of counties and referral regions, can contribute to identification of immediate problems as well as targets for longer term investment and policy response.

From Health in All Policies to Health for All Policies.

Worldwide responses to the COVID-19 pandemic have shown that it is possible for politicians to come together across departmental boundaries. To this end, in many countries, heads of government and their health ministers work closely with all other ministries, departments, and sectors, including social affairs, internal affairs, foreign affairs, research and education, transport, agriculture, business, and state aid. In this Viewpoint, we ask if and how the Sustainable Development Goals (SDGs) can support intersectoral collaboration to promote health, since governments have already committed to achieving them. We contend that SDGs can do so, ultimately advancing health while offering co-benefits across society.

Regional International Organizations and Health: A Framework for Analysis.

CONTEXT: Regional international organizations (RIOs), from the South African Development Community (SADC) to the European Union (EU), are organizations that promote cooperation among countries in a specific region of the world. Asking what RIOs do to health and health policy by looking only at their formal health policies can understate their effects (e.g., a free trade agreement with no stated health goals can affect health policy) and overstate their effects (as with agreements full of ambition that did not deliver much). METHODS: We adopt a "three-faces" framework that identifies RIOs' direct health policies, the effects of their trade and market policies, and their effects on health via fiscal governance of their member states to better capture their health impact. We tested the usefulness of the framework by examining the Association of Southeast Asian Nations, EU, North American Free Trade Agreement, SADC, and the Union of South American Nations. FINDINGS: All RIOs had some impact on health systems and policies, and, in many cases, the principal policies were not identified as health policy. CONCLUSIONS: Such a framework will be useful in understanding the effects of RIOs on health systems and policies because it captures indirect and even unintended health effects in a way that permits development of explanatory theories.

Perspectives in the study of the political economy of COVID-19 vaccine regulation.

Vaccines against SARS-CoV-2 continue to be developed at an astonishingly quick speed and the early ones, like Pfizer and Moderna, have been shown to be more effective than many public health scientists had dared to hope. As COVID-19 vaccine research continues to progress, the world's eyes are turning toward medicine regulators. COVID-19 vaccines need to be authorized for use in each country in which the pharmaceutical industry intends to commercialize its product. This results in a patchwork of regulations that can influence the speed at which products are launched and the standards that govern them. In this research forum article, we discuss several key questions about COVID-19 vaccine regulations that should shape research on the next stage of the pandemic response. We call for a research agenda that looks into the political economy of pharmaceutical regulation, particularly from a comparative perspective, including Global South countries.

Health, federalism and the European Union: lessons from comparative federalism about the European Union.

Bringing together the results of a large-scale review of European Union (EU) policies affecting health and a large-scale analysis of social policy and federalism, this paper uses comparative federalism to identify the scope and tensions of EU health policy at the end of the Juncker Commission. Viewing health care and public health policy through the lens of comparative federalism highlights some serious structural flaws in EU health policy. The regulatory state form in which the EU has evolved makes it difficult for the EU to formulate a health policy that actually focuses on health. Of the three faces of EU health policy, which are health policy, internal market policy and fiscal governance, health policy is legally, politically and financially the weakest. A comparison of the EU to other federations suggests that this creates basic weaknesses in the EU's design: its key powers are regulatory and its redistribution minimal. No federal welfare state so clearly pools risks at a low level while making markets so forcefully or creating rights whose costs are born by other levels of government. This structure, understandable in light of the EU's history and development, limits its health and social policy initiatives and might not be stable over the long term.

Termites of Solidarity in the House of Austerity: Undermining Fiscal Governance in the European Union.

European Union (EU) fiscal governance, especially the European Semester, is an ambitious new governance architecture involving surveillance and discipline, across both Eurozone and non-Eurozone member state policies, in pursuit of fiscal rigor. It is the most recent of several attempts to expand EU powers over member state policy with the goal of austere budgeting, and one that has led to remarkable claims of authority by the EU over member state health policies as detailed as medical school admissions and the role of primary care. It is expected that it would be resisted not just by those who object to an EU role in the organization and delivery of health care but also by those who object to a particular austere approach to health policy. How well is it working? Using two waves of interviews and documentary analysis, and health as a policy case study, the authors document three key techniques that opponents use to undermine the semester's governance architecture: broadening goals, expanding the scope of conflict, and disputing and nuancing indicators. The result is that opponents of a narrow fiscal governance agenda are again successfully undermining the narrow focus of the semester.

What Is EU Public Health and Why? Explaining the Scope and Organization of Public Health in the European Union.

Public health is notoriously difficult to define, and that is the case for public health in the European Union as much as other political systems. In this article, the authors try to identify the actual scope and meaning of public health as it is institutionalized in the EU political system. Using a mixture of historical policy and legal analysis, the authors show how the evolution of the institutional space called public health in the EU has been shaped by the EU's distinctive constitutional nature, its focus on regulation, and the legacy of its focus on market making as well as the preferences of its political leaders. The European Union does have an increasingly large space named "public health," in which health ministers, the health directorate-general, and invocation of its public health treaty article 168 can be found, as well as a much broader and older area of activities justified by the need to manage adverse health consequences of market-making policies in other areas such as labor standards and agriculture. The COVID-19 crisis of 2020 not only led to a strengthening of EU public health but also showed that the EU is one of the many political systems in which the legal and bureaucratic domain of public health is far smaller than the actual issues affecting the public's health.

Power and Purchasing: Why Strategic Purchasing Fails.

Policy Points Strategically purchasing health care has been and continues to be a popular policy idea around the world. Key asymmetries in information, market power, political power, and financial power hinder the effective implementation of strategic purchasing. Strategic purchasing has consistently failed to live up to its promises for these reasons. Future strategies based on strategic purchasing should tailor their expectations to its real effectiveness. CONTEXT: Strategic purchasing of health care has been a popular policy idea around the world for decades, with advocates claiming that it can lead to improved quality, patient satisfaction, efficiency, accountability, and even population health. In this article, we report the results of an inquiry into the implementation and effects of strategic purchasing. METHODS: We conducted three in-depth case studies of England, the Netherlands, and the United States. We reviewed definitions of purchasing, including its slow acquisition of adjectives such as strategic, and settled on a definition of purchasing that distinguishes it from the mere use of contracts to regulate stable interorganizational relationships. The case studies review the career of strategic purchasing in three different systems where its installation and use have been a policy priority for years. FINDINGS: No existing health care system has effective strategic purchasing because of four key asymmetries: market power asymmetry, information asymmetry, financial asymmetry, and political power asymmetry. CONCLUSIONS: Further investment in policies that are premised on the effectiveness of strategic purchasing, or efforts to promote it, may not be worthwhile. Instead, policymakers may need to focus on the real sources of power in a health care system. Policy for systems with existing purchasing relationships should take into account the asymmetries, ways to work with them, and the constraints that they create.

The comparative politics of COVID-19: The need to understand government responses.

COVID-19 has created a ramifying public health, economic, and political crisis throughout many countries in the world. While globally the pandemic is at different stages and far from under control in some countries, now is the time for public health researchers and political scientists to start understanding how and why governments responded the way they have, explore how effective these responses appear to be, and what lessons we can draw about effective public health policymaking in preparation of the next wave of COVID-19 or the next infectious disease pandemic. We argue that there will be no way to understand the different responses to COVID-19 and their effects without understanding policy and politics. We propose four key focuses to understand the reasons for COVID-19 responses: social policies to crisis management as well as recovery, regime type (democracy or autocracy), formal political institutions (federalism, presidentialism), and state capacity (control over health care systems and public administration). A research agenda to address the COVID-19 pandemic that takes politics as a serious focus can enable the development of more realistic, sustainable interventions in policies and shape our broader understanding of the politics of public health.

What Is the Affordable Care Act a Case of? Understanding the ACA through the Comparative Method.

International comparisons of US health care are common but mostly focus on comparing its performance to peers or asking why the United States remains so far from universal coverage. Here the authors ask how other comparative research could shed light on the unusual politics and structure of US health care and how the US experience could bring more to international conversations about health care and the welfare state. After introducing the concept of casing-asking what the Affordable Care Act (ACA) might be a case of-the authors discuss different "casings" of the ACA: complex legislation, path dependency, demos-constraining institutions, deep social cleavages, segmentalism, or the persistence of the welfare state. Each of these pictures of the ACA has strong support in the US-focused literature. Each also cases the ACA as part of a different experience shared with other countries, with different implications for how to analyze it and what we can learn from it. The final section discusses the implications for selecting cases that might shed light on the US experience and that make the United States look less exceptional and more tractable as an object of research.

Do parties make a difference? A review of partisan effects on health and the welfare state.

BACKGROUND: Do political parties matter to health? Do they affect population health either directly or through welfare states' social policies and the eligibility, affordability and quality of health systems? And if they do, how? These are crucial questions if we are to understand health politics or shape public health policy, particularly given the changing landscape of political parties, party dominance in the executive and the mediating influence of the legislature. METHODS: Using a systematic approach, this review examines 107 peer-reviewed articles and books published after 1978 focusing on high-income countries asking the overarching question: Do political parties matter to health and the welfare state? RESULTS: The literature relating parties to health directly was surprisingly thin, thus, the welfare state was used as a 'proxy' variable. An overwhelming majority of the literature sample suggests that Left parties are inclined to expand the welfare state without cutting benefits, while the Right does not expand and tends to reduce benefits. There was an inflection in the 1980s when Left parties shifted from expansion to maintaining the status quo. CONCLUSION: Considering current health trends in the form of measles outbreaks, the 'Deaths of Despair', the rise of previous eradicated infectious diseases and the declining health expectancy rates in some Western countries as well as the rise of Populist Radical Right parties in office we question the current partisanship thesis that political parties matter less and less.

Transforming health care: the policy and politics of service reconfiguration in the UK's four health systems.

Public involvement in service change has been identified as a key facilitator of health care transformation (Foley et al., 2017) but little is known about how health policy influences whether and how organisations involve the public in change processes. This qualitative study compares policy and practice for involving the public in major service changes across the UK's four health systems (England, Northern Ireland, Wales and Scotland). We analysed policy documents, and conducted interviews with officials, stakeholders, NHS staff and public campaigners (total number of interviewees = 47). Involving the public in major service change was acknowledged as a policy challenge in all four systems. Despite ostensible similarities, there were some clear differences between the four health systems' processes for involving patients and the public in major changes to health services. The extent of central Government oversight, the prescriptiveness of Government guidance, the role for intermediary bodies and arrangements for independent scrutiny of contentious decisions all vary. We analyse how health policy in the four systems has used 'sticks' and 'sermons' to promote particular approaches, and conclude that both policy and the wider system context within which health care organisations try to effect change are significant, and understudied aspect of contemporary practice.

Lessons for the United States From Single-Payer Systems.

US political debates often refer to the experience of "single-payer" systems such as those of Canada and the United Kingdom. We argue that single payer is not a very useful category in comparative health policy analysis but that the experiences of countries such as Canada, the United Kingdom, Spain, Sweden, and Australia provide useful lessons. In creating universal tax-financed systems, they teach the importance of strong, unified governments at critical junctures-most notably democratization. The United States seems politically hospitable to creating such a system.The process of creation, however, highlights the malleability of interests in the health care system, the opportunities for creative coalition building, and the problems caused by linking health care finance and reform. In maintaining these systems, keeping the middle class supportive is crucial to avoiding universal health care that is essentially a program for the poor.For a technical term from the 1970s, "single-payer health care" has proved to have remarkable political power and persistence. We argue it is not a very useful term but the lessons from such systems can be valuable for those contemplating movement toward universal health coverage in the United States.

Quantifying inequities in US federal response to hurricane disaster in Texas and Florida compared with Puerto Rico.

If disaster responses vary in their effectiveness across communities, health equity is affected. This paper aims to evaluate and describe variation in the federal disaster responses to 2017 Hurricanes Harvey, Irma and Maria, compared with the need and severity of storm damage through a retrospective analysis. Our analysis spans from landfall to 6 months after landfall for each hurricane. To examine differences in disaster responses across the hurricanes, we focus on measures of federal spending, federal resources distributed and direct and indirect storm-mortality counts. Federal spending estimates come from congressional appropriations and Federal Emergency Management Agency (FEMA) records. Resource estimates come from FEMA documents and news releases. Mortality counts come from National Oceanic and Atmospheric Administration (NOAA) reports, respective vital statistics offices and news articles. Damage estimates came from NOAA reports. In each case, we compare the responses and the severity at critical time points after the storm based on FEMA time logs. Our results show that the federal government responded on a larger scale and much more quickly across measures of federal money and staffing to Hurricanes Harvey and Irma in Texas and Florida, compared with Hurricane Maria in Puerto Rico. The variation in the responses was not commensurate with storm severity and need after landfall in the case of Puerto Rico compared with Texas and Florida. Assuming that disaster responses should be at least commensurate to the degree of storm severity and need of the population, the insufficient response received by Puerto Rico raises concern for growth in health disparities and increases in adverse health outcomes.

It’s the governance, stupid! TAPIC: a governance framework to strengthen decision making and implementation

This policy brief’s key messages are: governance is a broad and complex topic with many overlapping definitions, frameworks and recommendations, but governance concepts and ideas found in the literature can broadly be grouped into five key domains: Transparency, Accountability, Participation, Integrity and Capacity (TAPIC); governance is crucial to successful policy-making and implementation. It affects the likelihood that workable policies are adopted, that they are implemented, and that they produce intended results. At the same time, governance may be the cause of policy problems. But it is only one potential cause of problems, alongside other causes of failure such as inadequate finance.; each of the five domains of the TAPIC framework contains many different techniques for policy and procedural change. Rigorous and context-sensitive analysis is required to work out which domains contain governance problems and what those problems might be.

Everything you always wanted to know about European Union health policies but were afraid to ask

What does the European Union (EU) mean for health? What can it mean for health? This comprehensively revised second edition answers these questions. It provides a broad review and analysis of EU public health policies to mid-2019. It begins by explaining the basic politics of European integration and European policy-making in health, including the basic question of how the EU came to have a health policy and what that policy does. Thereafter, it moves on to the three faces of EU health policy. The first face is explicit health policy, both public health policy and policies to strengthen health services and systems in areas such as cancer, and communicable diseases. The second face is internal market building policies, which are often more consequential for health services, but are not made with health as a core objective. These include professional and patient mobility, regulation of insurers and health care providers, and competition in health care. They also include some of the policies through which the EU has had dramatic and positive health effects, namely environmental regulation, consumer protection and labour law. The third face is fiscal governance, in which the EU institutions police member state decisions, including relating to health. Each face has different politics, law, policy and health effects. The book provides a synthesis of the different faces and the different ways in which they have been used to strengthen or weaken public health and health systems in Europe. It shows the many, often unappreciated, ways that the EU has worked for health, as well as the opportunities to further strengthen the EU's positive impact on health. This book is aimed at policy-makers and students of health systems in the EU who seek to understand how the influence of the EU on health policy affects those systems and their patients. To ensure that the EU’s impact on health is wholly positive, the wider health community must understand and engage with the EU in the future – something this book aims to encourage.