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.

Impact on the NHS and health of the UK's trade and cooperation relationship with the EU, and beyond.

The UK's relationship with the European Union (EU) is now embodied in two principal legal instruments: the EU-UK Trade and Cooperation Agreement, which formally entered into force on 1 May 2021; and the Withdrawal Agreement, with its Protocol on Ireland/Northern Ireland, which continues to apply. Using a 'building blocks' framework for analysis of national health systems derived from the World Health Organisation, this article examines the likely impacts in the UK of this legal settlement on the National Health Service (NHS), health and social care. Specifically, we determine the extent to which the trade, cooperation and regulatory aspects of those legal measures support positive impacts for the NHS and social care. We show that, as there is clear support for positive health and care outcomes in only one of the 17 NHS 'building blocks', unless mitigating action is taken, the likely outcomes will be detrimental. However, as the legal settlement gives the UK a great deal of regulatory freedom, especially in Great Britain, we argue that it is crucial to track the effects of proposed new health and social care-related policy choices in the months and years ahead.

Centralizing and decentralizing governance in the COVID-19 pandemic: The politics of credit and blame.

COVID-19 led to significant and dynamic shifts in power relations within and between governments, teaching us how governments make health policies and how health crises affect government. We focus on centralization and decentralization within and between governments: within government, meaning the extent to which the head of government controls policy; and between governments, meaning the extent to which the central government pre-empts or controls local and regional government. Political science literature suggests that shifting patterns of centralization and decentralization can be explained by leading politicians' efforts to gain credit for popular actions and outcomes and deflect blame for unpopular ones. We test this hypothesis in two ways: by coding the Health Systems Response Monitor's data on government responses, and through case studies of the governance of COVID-19 in Austria, Czechia and France. We find that credit and blame do substantially explain the timing and direction of changes in centralization and decentralization. In the first wave, spring 2020, heads of government centralized and raised their profile in order to gain credit for decisive action, but they subsequently tried to decentralize in order to avoid blame for repeated restrictions on life or surges of infection. These findings should shape advice on governance for pandemic response.

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.

Can Comorbidity Data Explain Cross-State and Cross-National Difference in COVID-19 Death Rates?

Many efforts to predict the impact of COVID-19 on hospitalization, intensive care unit (ICU) utilization, and mortality rely on age and comorbidities. These predictions are foundational to learning, policymaking, and planning for the pandemic, and therefore understanding the relationship between age, comorbidities, and health outcomes is critical to assessing and managing public health risks. From a US government database of 1.4 million patient records collected in May 2020, we extracted the relationships between age and number of comorbidities at the individual level to predict the likelihood of hospitalization, admission to intensive care, and death. We then applied the relationships to each US state and a selection of different countries in order to see whether they predicted observed outcome rates. We found that age and comorbidity data within these geographical regions do not explain much of the international or within-country variation in hospitalization, ICU admission, or death. Identifying alternative explanations for the limited predictive power of comorbidities and age at the population level should be considered for future research.

Brexit and trade policy: an analysis of the governance of UK trade policy and what it means for health and social justice.

BACKGROUND: There is an extensive body of research demonstrating that trade and globalisation can have wide-ranging implications for health. Robust governance is key to ensuring that health, social justice and sustainability are key considerations within trade policy, and that health risks from trade are effectively mitigated and benefits are maximised. The UK's departure from the EU provides a rare opportunity to examine a context where trade governance arrangements are being created anew, and to explore the consequences of governance choices and structures for health and social justice. Despite its importance to public health, there has been no systematic analysis of the implications of UK trade policy governance. We therefore conducted an analysis of the governance of the UK's trade policy from a public health and social justice perspective. RESULTS: Several arrangements required for good governance appear to have been implemented - information provision, public consultation, accountability to Parliament, and strengthening of civil service capacity. However, our detailed analyses of these pillars of governance identified significant weaknesses in each of these areas. CONCLUSION: The establishment of a new trade policy agenda calls for robust systems of governance. However, our analysis demonstrates that, despite decades of mounting evidence on the health and equity impacts of trade and the importance of strong systems of governance, the UK government has largely ignored this evidence and failed to galvanise the opportunity to include public health and equity considerations and strengthen democratic involvement in trade policy. This underscores the point that the evidence alone will not guarantee that health and justice are prioritised. Rather, we need strong systems of governance everywhere that can help seize the health benefits of international trade and minimise its detrimental impacts. A failure to strengthen governance risks poor policy design and implementation, with unintended and inequitable distribution of harms, and 'on-paper' commitments to health, social justice, and democracy unfulfilled in practice. Although the detailed findings relate to the situation in the UK, the issues raised are, we believe, of wider relevance for those with an interest of governing for health in the area of international trade.

Social policy as an integral component of pandemic response: Learning from COVID-19 in Brazil, Germany, India and the United States.

It is easy but mistaken to think that public health emergency measures and social policy can be separated. This paper compares the experiences of Brazil, Germany, India and the United States during their 2020 responses to the COVID-19 pandemic to show that social policies such as unemployment insurance, flat payments and short-time work are crucial to the effectiveness of non-pharmaceutical interventions as well as to their political sustainability. Broadly, public health measures that constrain economic activity will only be effective and sustainable if paired with social policy measures that enable people to comply without sacrificing their livelihoods and economic wellbeing. Tough public health policies and generous social policies taken together proved a success in Germany. Generous social policies uncoupled from strong public health interventions, in Brazil and the US during the summer of 2020, enabled lockdown compliance but failed to halt the pandemic, while tough public health measures without social policy support rapidly collapsed in India. In the COVID-19 and future pandemics, public health theory and practice should recognise the importance of social policy to the immediate effectiveness of public health policy as well as to the long-term social and economic impact of pandemics.

Assessing the potential impact on health of the UK's future relationship agreement with the EU: analysis of the negotiating positions.

While policy attention is understandably diverted to COVID-19, the end of the UK's post-Brexit 'transition period' remains 31 December 2020. All forms of future EU-UK relationship are worse for health than EU membership, but analysis of the negotiating texts shows some forms are better than others. The likely outcomes involve major negative effects for NHS staffing, funding for health and social care, and capital financing for the NHS; and for UK global leadership and influence. We expect minor negative effects for cross border healthcare (except in Northern Ireland); research collaboration; and data sharing, such as the Early Warning and Response System for health threats. Despite political narratives, the legal texts show that the UK seeks de facto continuity in selected key areas for pharmaceuticals, medical devices, and equipment [including personal protective equipment (PPE)], especially clinical trials, pharmacovigilance, and batch-testing. The UK will be excluded from economies of scale of EU membership, e.g. joint procurement programmes as used recently for PPE. Above all, there is a major risk of reaching an agreement with significant adverse effects for health, without meaningful oversight by or input from the UK Parliament, or other health policy stakeholders.

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.

Neither protective nor harmonized: the crossborder regulation of medical devices in the EU.

To what extent does inadequate market regulation contribute to poor health outcomes? A series of prominent scandals involving harmful medical devices has made improving the regulation of these devices an urgent problem for the European Union (EU). This is, however, a specific example of a general phenomenon. The EU remains first and foremost a large and integrated market within which the EU institutions have considerable regulatory authority. Even if there is little EU commitment to a health or social policy agenda, its use of that regulatory authority shapes health care cost and quality and should be understood as health policy. We use data from EU-level and national policy documents to analyse the EU's current regulatory framework for medical devices and assess its likely future efficacy. Despite revising the medical devices directive to require more stringent pre-authorization requirements for high-risk medical devices and improvements in post-market surveillance, the key underlying problems of market fragmentation and patient safety persist. Without strong and consistent support for the implementation of the new directive, the likely result is the status quo, with significant consequences for health in Europe.

Centralisation and decentralisation in a crisis: How credit and blame shape governance

The COVID-19 pandemic led to unprecedented challengesand political creativity worldwide. In governance, this often led to unexpected centralisation and decentralisation in response to case surges. Changes in the distribution of power and responsibility throughout governments changed quickly as the pandemic progressed. Centralisation and decentralisation occurred within governments and between governments, as power shifted. The main explanation for the patterns of centralisation and decentralisation is the politics of credit and blame. Politicians at all levels seek to centralise when there is credit to be had from forceful action and decentralise when there are unpopular policies or bad news coming.

An Analytical Perspective on Pandemic Recovery.

After implementing restrictions to curb the spread of coronavirus, governments in the United States and around the world are trying to identify the path to social and economic recovery. The White House and the Centers for Disease Control and Prevention have published guidelines to assist US states, counties, and territories in planning these efforts. As the impact of the coronavirus pandemic has not been uniform, these central guidelines need to be translated into practice in ways that recognize variation among jurisdictions. We present a core methodology to assist governments in this task, presenting a case for appropriate actions at each stage of recovery based on scientific data and analysis. Specifically, 3 types of data are needed: data on the spread of disease should be analyzed alongside data on the overall health of the population and data on infrastructure-for example, the capacity of health systems. Local circumstances will produce different needs and present different setbacks, and governments may need to reinstate as well as relax restrictions. Transparent, defensible analysis can assist in making these decisions and communicating them to the public. In the absence of a widely administered vaccine, analysis remains one of our most important tools in addressing the coronavirus pandemic.

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.

Brexit is just a symptom: the constitutional weaknesses it reveals have serious consequences for health.

Brexit has direct and indirect negative health consequences, whether from economic damage or from the political paralysis and distraction from public health that it has created. Brexit is a public health problem in its own right, as other literature has shown-but, we argue, it is also a symptom of deeper problems in the governance of the United Kingdom. In particular, the combination of executive dominance, partisanship and opacity that give rise to the constitutional casualism of the Brexit decisions has already affected public health policy and will continue to do so unless addressed.