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.

Policy Makes Politics Comment on "Modelling the Health Policy Process: One Size Fits All or Horses for Courses?"

Powell and Mannion's review of reviews maps the landscape of health policy research, showing a number of problematic and longstanding features. This commentary focuses on the extent to which health parochialism is good for the scientific development of the literature, the extent to which a "tournament of theories" actually develops our understanding of health policy process, and, finally, whether circumscribed theories of the policy process might be missing some of the most important and useful findings of broader comparative politics, which focus on the ways policies create politics over time. It concludes that health parochialism and focus on a circumscribed policy process is not likely to be helpful because it distracts attention from the ways in which coalitions and institutions over time shape politics and policy, a finding explored by scholars of many sectors whose findings should influence health policy research.

Pivot: partisan policy responses to COVID-19 health disparities.

How did partisanship influence rhetoric about, public opinion of, and policies that prioritize racial and ethnic health disparities of COVID-19 during the first wave of the pandemic between March and July 2020? In this retrospective, mixed-methods analysis using national administrative and survey data, we found that the rhetoric and policy of shared sacrifice diminished and partisan differences in pandemic policy increased once it became clear to political elites that there were major racial disparities in COVID-19 cases and deaths. We trace how first disparities emerged in data and then were reported in elite, national media, discussed in Congress, and reflected in public opinion. Once racial disparities were apparent, partisan divides opened in media, public opinion, and legislative activity, with Democrats foregrounding inequality and Republicans increasingly downplaying the pandemic. This temporal dimension, focusing on how the diffusion of awareness of inequalities among elites shaped policy in the crucial months of early 2020, is the principal novel finding of our analysis. Overall, there is a clear, partisan policy response to addressing COVID-19 racial disparities across media, public opinion, subnational legislative activity, and congressional deliberations.

How do you solve a problem like Maria? The politics of disaster response in Puerto Rico, Florida and Texas.

COVID-19 is not the first, nor the last, public health challenge the US political system has faced. Understanding drivers of governmental responses to public health emergencies is important for policy decision-making, planning, health and social outcomes, and advocacy. We use federal political disaster-aid debates to examine political factors related to variations in outcomes for Puerto Rico, Texas, and Florida after the 2017 hurricane season. Despite the comparable need and unprecedented mortality, Puerto Rico received delayed and substantially less aid. We find bipartisan participation in floor debates over aid to Texas and Florida, but primarily Democrat participation for Puerto Rican aid. Yet, deliberation and participation in the debates were strongly influenced by whether a state or district was at risk of natural disasters. Nearly one-third of all states did not participate in any aid debate. States' local disaster risk levels and political parties' attachments to different racial and ethnic groups may help explain Congressional public health disaster response failures. These lessons are of increasing importance in the face of growing collective action problems around the climate crisis and subsequent emergent threats from natural disasters.

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.

From Health in All Policies to Health for All Policies.

Worldwide responses to the COVID-19 pandemic have shown that it is possible for politicians to come together across departmental boundaries. To this end, in many countries, heads of government and their health ministers work closely with all other ministries, departments, and sectors, including social affairs, internal affairs, foreign affairs, research and education, transport, agriculture, business, and state aid. In this Viewpoint, we ask if and how the Sustainable Development Goals (SDGs) can support intersectoral collaboration to promote health, since governments have already committed to achieving them. We contend that SDGs can do so, ultimately advancing health while offering co-benefits across society.

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.

Strategic purchasing and health systems resilience: Lessons from COVID-19 in selected European countries.

Strategic purchasing is a popular and frequently proposed policy for improving the efficiency and adaptiveness of health systems. The COVID-19 pandemic shocked health systems, creating a test of the adaptability and resiliency of their key features. This research study explores (i) what role purchasing systems and agents played in the COVID-19 pandemic, (ii) if it was strategic, and (iii) how it has contributed to a resilient health system. We conducted a qualitative, comparative study of six countries in the European Union-focusing on three as in-depth case studies-to understand how and when strategic purchasers responded to seven clearly defined health system "shocks" that they all experienced during the pandemic. We found that every case country relied on the federal government to fund and respond to the pandemic. Purchasers often had very limited, and if any then only passive, roles.

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.

The politics of healthy ageing: myths and realities

Research from the European Observatory’s Economics of Health and Active Ageing series finds overwhelmingly that population ageing is not a major problem for the sustainability of health care systems or societies. So why is it so often treated as a threat? This brief draws on a book presenting and synthesizing the international evidence on this question. It first identifies three myths that are widely influential in debates about ageing. The myths are that ageing societies are fiscally unsustainable, that older people prefer better benefits for themselves at the expense of younger people, and that politicians give older people what they want – benefits for older people at the expense of younger generations. If these myths were true, there would indeed be a major crisis in the increasing number of ageing societies. The brief and research discussed in it find that none of these three myths is true. The brief then reviews evidence on the possibility of ‘win–win’ politics that produce good outcomes for people of all ages. In terms of policy design, this means focusing on life-course policies. Life-course approaches have extensive implications for policy because they suggest ways to make policies that invest for the future at every stage of people’s lives. They also have distinctive politics because they ask for political leaders, interests and advocates to form coalitions among different groups that mutually benefit from the same policies. The brief concludes with lessons on ways to develop political coalitions in support of life-course policies.