Transcript Diapositive 1

The Europeanization
of Health Policy
Monika STEFFEN
Institute for Political Studies
University of Grenoble (France)
Fiocruz / ENSP, Rio de Janeiro
27th 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:
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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, professionals
2.Financing, social security provision for illness
3. Public health and prevention (tobacco, alcohol, STD…): direct goal
4. Policies with health impact (agrifood, environment…): indirect goal
5. 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
Political context
Economic context
Institutional
context
Policy
decision
Complementary approaches
to “EU health policy”
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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
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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
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)
M. Steffen - M2 PPS 2010
10
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
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• 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