European Public Health Actors and Trends

The following table introduces the actor landscape of the European public health (policy) community.

Table 1: Actor Overview

Level / Kind Stakeholder(s) Role / Function International;

intergovernmental

WHO: Regional Office for Europe

Supporting governments and the EU in generating and using appropriate health information, health care delivery and the management of health systems (cf. WHA, 2016⁶)

Supranational European Union Regulatory role and various financial program-based instruments from European Commission (EC) (Ruijter, 2019, 60):

- EU health programme - Regional funding to reduce

inequalities between European

6 Documents that appear in the text AND are analysed in chapter 5 such as this quote are cited twice, in Annex 8 and in the general list of references – documents analysed in chapter 5 that do not appear in other chapters are only cited in Annex 8

32 regions with different population health outcomes

- Funding for research (cf. EC, n.d.)

National 53 state governments Legal mandate to design health systems and policies (Ruijter, 2019); partially limited in power, only effective instrument: finance (Gooijer, 2007, xviii)

Emerging Actors (foundations, private, half-private)

Pharmaceutical, clinical and medico-technical companies, private health insurances, management and consulting firms, public-private

partnerships, philanthropic foundations

Industries possess strong lobby force (Koivusalo, 2005, 337);

Private loans for investments in public sector (Ferreira & Mendes, 2018, 2165);

Pharmaceutical industry has direct impact on health care expenses (de Vos et al., 2004);

philanthropic foundations distort priority setting (GHW 5, 2017, 263ff.)

Individual 1. Health

professionals and staff

2. Patients

Both shape perception and approach to health, have decision-making power on the local level when implementing policies / regulations (Mooney, 2012)

Organized civil society actors on global, regional, national or local level (focus of this research)

e.g. People’s Health Movement, Health Care Without Harm or organizations listed in chapter 6 and 7

Policy advocacy, service provision, dissemination of information, resource mobilization, monitoring, networking,

supporting or conducting research (Beinare &

McCartney, 2011, 892; Malinowska-Sempruch et al., 2006, 626)

Civil society EU partner

organizations (excluded from research)

e.g. European Observatory on Health Systems and Policy, EU Health Policy Platform, European Public Health Association, (n.a., 2019; EU, 2019)

Similar as above, partially more

professionalized, often disconnected from grassroots level and closer to political power (cf. Kohler-Koch & Quittkat, 2009)

Unorganized civil society (excluded from research)

Individuals and small or temporary social movements

Establishing and pressuring for political will, support, monitoring (cf. Ceukelaire et al., 2011, 1188)

Source: own collection, oriented at Mooney, 2012

The following sub sections elaborate on the characteristics and associated trends of the most relevant actor types for the findings presented in the chapter 5-7. Even though other actors which are excluded in the chapter are decisive for health governance as for instance national governments deciding over the amount and allocation of funding or national environmental and public health agencies, these national characteristics are not essential for this thesis’ analysis of the overall European public policy

33 trends. Therefore, this section rather zooms in on the role of the EU, the WHO as well as rapidly emerging actors such as private-public-partnerships and philanthropical foundations in health.

4.2.1. The EU

The EU’s involvement in public health policy, representative for only 27 of the analysed 53 countries, is growing (Ruijter, 2019, 63). Generally, the EU only owns an advisory role regarding health issues and is responsible for raising concerns and to encourage countries to act on certain priority areas (GHW 5, 2017, 136). Yet, EU fiscal regulations and economic policies impact member states’ health budgets in various ways; first, via the ‘Stability and Growth Pact’ keeping member states’ budget deficits below 3% as well as debts below 60% of the respective GDP; second, via loan programs and the European Central Bank conditioning and pressuring to reduce health care costs such as after the financial crisis;

and third via the European semester, thus the recommendations for member states issued by the EC (CEO, 2021, 18). Health sector reforms constitute a recurring part of the recommendations and include the possibility of imposing fines (ibid, 18f.). De Vos et al. made such observations already in 2004 and concluded that since 1990, the EU “built a strict financial and political straitjacket, forcing these [national health] systems to carry out privatization and cutbacks” (255).

According to Koivusalo (2005), the European social model – the way of collectively committing to universal health coverage and solidary financing – is under threat (325). Internal market policies, indicating the introduction of competition in health systems, and the streamlining of various social policies rather serve the goals of the economic sector (ibid; de Vos et al., 2004, 266). European institutions create a policy framework favouring the pharma industry instead of restricting the market in health (ibid, 260).

Even though the EU in its more regulative, supportive role does not yield direct legal or political power on national or local policy making, it owns the unique position of changing the governance directive in the fields of general economic policy as outlined above but also in trade, services and intellectual property rights policies (Mooney, 2012). Therefore, the EU carries a major part of the responsibility for the outlines of the current political economic system.

4.2.2. The WHO / WHO Regional Office for Europe

The WHO and its regional offices work to expand universal health coverage, direct and coordinate responses to health emergencies and promote healthier lives (WHO, 2021a). Despite the WHO’s central position in (European) public health governance, it currently undergoes a deep funding crisis

34 and is largely dependent on donors such as high-income nations or philanthropies (GHW 5, 2017, 245ff.). It can be said to serve as example for the general trend of an “erosion of [ …] democratic space” in global health (van de Pas & van Schaik, 2014, 195).

The WHO currently struggles to carry out its normative activities (GHW 5, 2017, 245). Private contributors are now able to cherry-pick their own priorities among public health challenges which mostly tends towards objectives which are simple to measure (ibid, 245ff.). As a direct consequence, more complex challenges are rarely funded – even though they often constitute the most central preconditions for population health, including health system strengthening, reducing NCDs and social and environmental health determinants (ibid, 253ff.).

All in all, one can say that the WHO lost its political importance relative to other emerging actors in the health governance landscape. As the central supposedly democratic actor in the field, the way the WHO deals with its donor dependency is decisive for commercialization processes as well as for the potential influence civil society can have on topics such as health equity and environmental health.

4.2.3. Emerging Actors

The shrinking democratic space opens doors to other actors determining priorities and owning power and resources in health. The process transforms from being driven by nations and (inter)governmental entities towards private foundations, corporations and consultancy firms (ibid). Integrated care systems or health care networks where government, market and civil society actors collaborate closely, also identify as a new trend in health care governance as visible in countries like the UK, Belgium or Denmark (Raus et al.,1ff.). Emerging actors include public-private partnerships and initiatives such as the Global Fund to Fight AIDS, Tuberculosis and Malaria or Gavi, the Vaccine Alliance (ibid, 298; Mooney, 2012).

Another actor type rapidly growing in its number, influence and scope are philanthropic foundations such as the Bill and Melinda Gates Foundations (GHW, 2017, 263). Philanthropic foundations apply business models to measure results and rely on technical solutions (ibid, 267f.). They efficiently achieve a range of priority goals set according to criteria of easy measurement, thereby again precluding comprehensive transparent redistributionist measures (funded for instance by the taxes they would otherwise pay) (ibid, 269ff.). By way of immense resources, expertise and high-level political networks, they influence the global public health agenda and fragment health governance by devaluing parliaments and democracy (ibid, 270f.; Patnaik, 2021, 10).

35 Another trend “undermining systemic, root-cause interventions” (GHW 5, 2017, 283) and favouring problem-fixing approaches relates to the rise of management consulting firms in health care undercutting civil society and communities (ibid, 286f.). Introducing a business language and fiscal-technical discourses, a language paradigm associated with power emerges and excludes less professionalized yet practically experienced local CSOs or activists (ibid). Consultancy firms also play a vital role in setting up internal markets in Europe providing the conditions for private profits in health (cf. CEO, 2021, 17). Hence, all trends follow a direction of more privatization and the integration of market principles into health. One can therefore conclude that civil society in health acts in an environment more and more shaped by private actors with resources decreasingly centred around public democratic institutions.

The expansion of the actor landscape and the tendency towards multilateralism in global public health, may compromise the WHO’s legitimacy further but in fact has been partly driven by the WHO itself (Patnaik, 2021, 5f.). Patnaik (2021) warns of the possibility that pushing civil society involvement might just be an attempt to legitimize the inclusion of private actors through a “multi-stakeholder approach” (16).

4.2.4. Civil Society

Multilevel governance has been a guiding principle of the European Union since 1992 (O’Gorman et al., 2014, 1003): Civil society is strongly and increasingly involved in policy making at the European and national level, yet comparatively less in Central and Eastern Europe, also due to political tradition and culture (cf. section 6.5; Franklin, 2016; Atun et al., 2008). CSOs have been advancing the Health in all Policies (HiaP) approach (cf. section 5.7.1.), participated in working out the SDGs and many more policies (Franklin, 2016, 30). Health CSOs traditionally work in areas like HIV/AIDS, vaccines, illicit drugs or drug policy advocacy (McCarthy & Knabe, 2012, 256; Spicer et al., 2011, 1752) – they are also active on health equity (Ceukelaire et al., 2011, 1185), yet, political will is required to combat deregulation and privatization (ibid, 1187).

The extent to which CSOs influence public health governance varies – in Italy, health care policy for instance for migrants has always been shaped by civil society (GHW 5, 2017, 144). According to Patnaik (2021), during the Covid pandemic, civil society actors are, contrary to their increased significance for public health governance in times of need, struggling to be heard (16). This research however suggests otherwise (cf. chapter 6-7).

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