Political Leadership and the European Health Union: A way forward for Health and Wellbeing

Vytenis Andriukaitis, WHO Envoy for the European Region, speaks with the Sciana Network

Vytenis Andriukaitis, WHO Envoy for the European Region, was the guest speaker for the Sciana Lecture last month.

In light of the COVID-19 pandemic, the lecture took place online instead of the familiar surroundings of Schloss Leopoldskron. On January 26, Sciana Chair Ilona Kickbusch hosted the event, inviting Sciana Members from all four cohorts.

Andriukaitis has previously served as the former European Commissioner for health and food safety, a former minister of health for Lithuania, and a heart surgeon.

In a Q&A with Kickbusch, he reflected on his leadership experience, the lessons he learned from holding different positions during his career, and his goal of seeking greater European cooperation on health and health care. At the end of the discussion with Kickbusch, Andriukaitis took several questions from Sciana Members.

A lifetime of extraordinary leadership

Andriukaitis started the discussion by revealing political leadership was never one of his objectives and that his life began in a Soviet gulag. He said, "This extraordinary experience of my childhood contributed to my burning desire to struggle, for freedom against totalitarian regimes, totalitarian rules, and against oppression."

He decided to become a doctor to serve people while gaining a better understanding of history and the "political calamities" that beset the 20th century. In the 1970s, he joined the dissident movement. But it wasn't until the late 80s and perestroika that changes appeared in Eastern Europe. He recognized, however, not all changes were for the better.

Following the Soviet Union's collapse, Andriukaitis opposed the free market's dominance in producing goods and services. He was particularly against the social sector's large-scale privatization and the pressures to transform social health insurance into privately managed schemes. However, he remained thankful to be on the frontlines in Lithuania's struggle for independence and efforts to engage with the European Union. He said, "Today, I am proud to see the possibilities of Europe in a broader sense."

As a European Commissioner who served between 2014 and 2019, he said it was essential to listen and understand the different member states, political families, and industries putting their "legitimate interests" forward. Andriukaitis said, "None of us is right 100 percent. Science and evidence-based assessment[s] of different policies [help] us move towards consensus."

Being a European Commissioner also required persistence and patience. Visions need to be communicated appropriately, and bold ideas need to be supported by technical detail. Andriukaitis recognizes the pressure people are under to act now, but he insisted "change needs time," and there should be trust in the European institutions.

Obstacles to cooperation

Andriukaitis is currently showing leadership by advocating for a European Health Union. Kickbusch asked him what the obstacles were that were preventing stronger cooperation. Andriukaitis said this was not an easy question to answer. Still, he began by pointing to the treaties establishing the European Coal and Steel Community, the European Economic Community, and the European Union [EU].

"The Treaty of Rome," Andriukaitis said, "aimed to work towards integration and economic growth, through trade, to create a common market based on the free movement of goods, people, services, and capital. In the fifties, the social sector was a relatively small part of the European economies. The perception of health and other social spheres as non-productive sectors were quite widespread at those times."

By the time the EU came into being, Andriukaitis claims health and safety had already established itself as one of the leading sectors of a modern economy, but the eighties "was a period of neoliberal thought and policies. From the eighties to nineties, European countries were preoccupied with [the] liberalization of national health systems and cost containment."

As a result, Andriukaitis believes member states have since been quite reluctant to cooperate on health matters. Yet, they have established their own national health services and made "already existing social insurance systems more generous." Until 2000, Andriukaitis says member states were moving towards universal health coverage based on "national decisions." The success of this process may have convinced some politicians stronger pan-European cooperation for health was not needed, according to Andriukaitis.

Health in all policies? Or just some?

Kickbusch said the COVID-19 pandemic was a realization there needs to be more cooperation on health. She questioned Andriukaitis whether this requires a treaty change or implementing existing agreements. Despite the EU's Health in All Policies approach, Kickbusch suggested there appeared to be many constraints.

Andriukaitis said the objective to promote good health is not explicitly mentioned in Article 3 of the Treaty on the European Union. In addition, the EU's legal services state they should intervene "only in cases where a Member State is deemed no longer to be able to cope with a crisis alone and requires assistance." The EU, however, can take action related to health in three areas, according to Andriukaitis. 

As a European Commissioner, Andriukaitis could take action relating to public health, but there were limitations. He described having 2.3 billion Euros each year for food safety in cows and poultry, but only 35 million Euros for the public health program. Andriukaitis could also involve himself in public health requirements included in the regulation of the EU single market. This covered legislative matters involving alcohol issues, acrylamides, tobacco, health technology assessment, and pharmaceuticals. However, Andriukaitis said, "In all of these, the leading issue is 'single market first,' not 'health first,' with industry playing a lot of games."

The third area Andriukaitis could get involved is through fiscal governance for health. However, he believes this area is underdeveloped. He said, "Because of the emphasis on the sustainability of public finances, it has led to repeated cuts in investment in public health systems… The fact that internal market almost always prevails upon public health concerns in the EU legislative initiatives is a proof, according to my opinion, of an existing constitutional 'asymmetry.'"

Despite these challenges, Andriukaitis welcomes the fact that Europeans are now debating the role of health in future policies. He said, "The intensity of the debate was almost unthinkable just a year ago. It looks like a call for a European Health Union is gaining strong support across the block at least during this health emergency created by COVID-19."

Andriukaitis is convinced health would have pushed its way to the centre of European politics even without the pandemic, citing the current high number of people employed in the health sector compared with economic industries that once dominated discussion at the start of European integration.  He said, "Old stories, however good, are no longer attractive to many Europeans. If you are thinking about how to bring Europe closer to its citizens, speak about health. Europeans care about their health."

Establishing a European Health Union

Andriukaitis outlined three scenarios to develop a European Health Union. The first scenario – scenario A - involves taking measures to make health progress by looking at what can be done within the existing legal, financial, and managerial instruments. The second scenario – scenario B - involves fine-tuning current health policy instruments in parallel to developing secondary legislation and establishing new institutions. But Andriukaitis is in favour of the third scenario: scenario C.

This scenario involves incorporating a provision for a European Health Union into the Treaty on the European Union. This action would give the EU some shared competencies while preserving the principle of subsidiarity as a core. Andriukaitis said, "If we continue within the current wording of European treaties, the risk is that the idea of the European Health Union will last no longer than the use of face masks in this pandemic!"

Andriukaitis said this action would be a game-changer. "Think about rare diseases," he said. "No one country alone can help the 20 million people with these diseases to have better diagnostics and treatment. 'Leave no one behind' is an excellent slogan, but people with rare diseases have been left behind until now… We need to have something at the pan-European level." 

Building coalitions

As a European Commissioner, Andriukaitis said he had to be smart to be instrumental in health promotion and disease prevention. One success story was the European Reference Networks, established between 2014 and 2019, that helped develop the care and curing of patients with rare diseases.

Andriukaitis also cited Europe's action against the Ebola virus as an example of the EU acting in cooperation with member states and international organizations for the sake of global health. He said, "The Ebola epidemic in West Africa was contained in two years: 2014 to 2016. It was a wake-up call to upgrade preparedness for health emergencies. The international community was quite successful against Ebola, but lessons learned appeared to be not enough to avert [the] COVID-19 pandemic."

On the international stage, Andriukaitis believes the EU can further assist countries in the World Health Organization European region to manage the COVID-19 pandemic. This assistance includes opening access to public goods developed by European bodies, such as the European Centre for Disease Prevention and Control and the European Medicines Agency.

Andriukaitis said, "Reduction of risks related to [the] cross-border spread of communicable diseases, [the] progress of wellbeing and social stability in neighboring countries, growth of soft power of the EU, are tangible returns on investment into global health.  The EU should be a donor, but at the same time has to ask for proper respect. It is time for the WHO to acknowledge the EU as a fully-fledged member of the organization."

Moving forward

Andriukaitis is encouraged by European Commission President Ursula von der Leyen's call for practical actions and believes her pledge to create the European Health Union was a bold and correct move. He said the Commission's current health-focused efforts had exceeded the expectations of most stakeholders in health. Nevertheless, he is concerned this momentum may stop.

"In their December meeting, the Council of Health Ministers expressed strong support for the development of a European Health Union, on a trajectory of the scenario A with elements of the scenario B," Andriukaitis said. "This is progress compared with the prevalent view just a year ago, but it is crucial that progress does not stop after constructing these first building-blocks."

Andriukaitis said the Conference on the Future of Europe, due to take place in May 2021, is a "perfect platform to integrate stronger cooperation for health into mainstream European policy, to discuss the European Health Union as an initiative with [the] potential to shape European politics for decades to come."

He added, "European leaders have a choice to start seriously debating the European Health Union this year or to postpone the discussion until the next public health emergency. Let us start now. I would like to finish my response [with] a quote from the [EHU] Manifesto. Let us be inspired by the words of Robert Shuman: World health 'cannot be safeguarded without making of creative efforts proportionate to the dangers which threaten it.'"

Read an extended edited transcript of Andriukaitis' conversation with Kickbusch.

Photo by European Parliament/Flickr