With this year’s Country Reports analysing key economic and social challenges in EU Member States, the European Commission further expanded on the social dimension of the European Semester. For the first time, inequalities have been addressed in a more comprehensive manner, with income inequalities and inequalities based on wealth distribution specifically emphasised. While the reports go into a substantial level of detail, a cursory look at their executive summaries offers a stable indicator of the content of the upcoming Country Specific Recommendations (CSRs).
The consideration of health specific issues in the Country Reports is closely linked to the average performance of Member States. If national health systems are performing below average, a larger number of issues are flagged up and identified for improvement. It is important to note that this does not pertain to cost-effectiveness only, but equally to access, quality, public spending, workforce issues, and most importantly population health outcomes. Access and health outcomes are strongly addressed for several CEE countries and the relatively high burden of chronic non-communicable diseases is highlighted. In some cases, and mostly for countries in Southern Europe, above average health outcomes are acknowledged, with additional health systems bottlenecks, such as, for instance, care coordination, identified as issues for improvement. In specific cases barriers to Universal Health Coverage (UHC) are identified, with notable links to high out-of-pocket payments (Cyprus, Bulgaria, Latvia). In addition, the issue of antimicrobial resistance (AMR) is addressed for the first time in the context of the European Semester. In the case of Cyprus, the high level of antibiotic consumption and non-prescription use of antibiotics are noted, with a reference to implementation of the national strategy for antimicrobial resistance.
While the sustainability of public finances in the health area remains a key issue that is often paired with demographic pressure and ageing societies, suggested measures to curb expenditure also target the strengthening of primary care, improvement of health promotion and disease prevention, and stepping up e-health measures. In addition, member states such as Latvia or Slovakia implementing healthcare reform measures which are also supported by EU funds, also get a longer dedicated health section with progress critically reviewed. Interestingly, a high risk to sustainability of the healthcare system is mentioned in the case of the UK, but the current report makes no mention of Brexit.
In sum, the European Semester process has made solid progress to emphasise the social dimension of economic policy coordination. However, it also suffers short-term memory. The effects of fiscal austerity have not just exacerbated structural weaknesses of domestic economies, but also profoundly affected social policies and public health in the long-term. In Latvia, health was on the frontline of budget cuts aiming to curb public expenditure, which has left the system paralysed and under-funded. Current government plans to increase spending may not be enough to restore funding to pre-crisis levels, while substantial delays are incurred at the implementation stage. In Italy, significant budget consolidation measures have prompted severe cuts on healthcare spending, followed by the introduction of co-payments. Country Specific Recommendations for Italy issued by the European Commission in 2011 and 2012 revolved around fiscal consolidation and this year’s Country Report acknowledged ‘progress’ made in this period to curb public expenditure. But elsewhere, the same report hints at the rise of out-of-pocket payments and disparities in access to care in Italy, while no obvious link to austerity measures is made.
It is undeniable that measures taken in the aftermath of the sovereign debt crisis have resulted in long-lasting effects on health and social services, often affecting the most vulnerable groups. While the high-level call for a ‘Social Triple A’ and the upcoming European Pillar of Social Rights seek to enhance Europe’s social dimension, social and economic divergences between and among member states have increased. A shift in discourse is therefore necessary, but can only be an intermediate step. More robust action with stronger focus on social investments, which include a holistic and integrated approach to public health challenges, need to be pursued for a Social Europe to deliver.