After years of ‘public bad, private good’ ideology in healthcare, the shock of the coronavirus calls for a post-crisis European strategy to advance public health.

Overburdened hospitals, lack of ventilators, supply bottlenecks for face masks and way too little testing capacity—the Covid-19 pandemic is by far the worst sanitary crisis in Europe since World War II. Health systems across the continent were however already on the verge of breakdown before the global coronavirus shock.

A couple of months earlier, 97 per cent of French hospitals were failing to fill vacancies and countrywide strikes of health workers shut down dozens of emergency departments—working conditions and wages in the French health sector suffer chronic underfunding. In Greece, public spending on health was cut in half between 2009 and 2016, following the recommendations of the ‘troika’ of European Commission, European Central Bank and International Monetary Fund: 13,000 doctors and 26,000 health workers lost their jobs and nearly half of Greek hospitals had to close their doors. In Germany, the privatisation of public hospitals has led to an investment backlog of €50 billion, with only 20 per cent of all hospitals having sufficient public-investment guarantees.

Paying dearly

In the current crisis, the member states of the European Union are paying dearly for these drastic cuts: between 2004 and 2014, the total number of intensive care beds in the EU dropped by 11 per cent. In France, there are no more than 11.6 intensive care beds for every 100,000 inhabitants, in Greece only six. With even Italy is better equipped (12.5), the disastrous condition of medical supply in Europe becomes obvious.

It is no coincidence that public health systems across the EU are compromised—and not only in those countries where the troika’s austerity ruled during the eurozone crisis. Even the less affected member states saw public expenditure on healthcare shrinking drastically over the last decade.

Hence, many health systems are deficient in collective funding and depend on private spending. In 2017, the share of private contributions in national health expenditures amounted to 46.5 per cent in Bulgaria and 44.6 per cent in Cyprus. Among the largest European economies, Italy and Spain show the poorest performance, relying on a 23.5 per cent private share in each case. The German Medical Association anticipates a rise in private contributions, from 12 to up to 30 per cent, in the next couple of years. 

In ‘liberalised’ systems, the law of the market rules: no longer a public good for all, healthcare becomes a ‘club’ good reserved for those who can afford it. In a global pandemic, however, lacking access to health services is not merely an individual problem for those concerned but a collective risk to our societies. Even if universal coverage for all citizens is politically promised, the problem remains: how will sufficient healthcare be guaranteed in the event of a crisis if the funds needed to invest in public infrastructure have been transformed into profits of private health entrepreneurs?

Sanitary and economic crises become mutually reinforcing: the medical emergency leads economies into a recession which weakens households’ purchasing power and undermines the liquidity of healthcare systems which rely on private expenditure. Once the health system has collapsed, the recession gathers further pace—a vicious circle. To avoid such crises, our health systems have to meet two criteria: they must be accessible and affordable for everyone and rely on solidaristic and stable funding. Provided decision-makers in the member states get to understand this, there is hope they use the post-crisis momentum to stop the misguided privatisation of public services.

Common answer

Given the global dimension of the crisis and the consequences which closed borders and a lack of solidarity will have for the future of the EU, we need to find a common European answer to the pandemic.

For the time being, the scope of EU health policy has been limited to the definition of hazardous substances, the regulation of drugs and health protection, especially occupational health. Those policy fields could become a point of departure for new methods of co-ordination which address not only regulatory standards but also the stability and security of supply of member states’ health systems.

As a first concrete measure of a common European health strategy, existing structures should be used more effectively: with a new competence for medical procurement, the European Medicines Agency and the European Centre for Disease Prevention and Control should take action to avoid supply backlogs. In the case of health crises, the EU could then acquire medical equipment and forward it to competent authorities and strategic distribution points in the member states, such as pharmacies and hospitals. Hence, member states would no longer be tempted to outdo each other in a despicable ‘procurement race’ at the expense of other countries.

Unconditional trust in the ‘invisible hand of the market’—where hitherto the competence to distribute medical equipment has de facto laid—has led to another undesirable development: due to large-scale outsourcing, the European pharmaceutical industry has become worryingly dependent on essential raw materials and equipment from third countries.

To counter this development, freedom for capital in the internal market should be restricted when it comes to hostile takeovers. Strategically important companies, such as CureVac, which is involved in essential research on vaccines and antidotes for Covid-19, should be part of a European agenda to promote investment in research and development and keep strategic research inside the EU.

Minimum standards

If we continue this idea, other policy fields enter the stage: a crisis-proof health union needs European minimum standards for public health funding. This implies common indicators, such as for emergency department capacities and intensive care beds, and binding upper limits for the share of private contributions in national health expenditures. In addition, strategic public investments and state participation in the healthcare sector must be agreed on at European level to guarantee affordable and accessible health care for every European citizen.

Since the Lisbon treaty entered into force in 2009, the EU has had a clear competence to co-ordinate and complete member states’ health policies: title XIV and especially article 168 of the Treaty on the Functioning of the EU provide a legal basis for the proposals set out here. The coronavirus shows us that the EU must not put member states’ public health systems up for sale. Where health and safety of all Europeans are at stake, member states have to work closely together—for no country will be able to solve the crisis on its own.