The "European Public Health" Reader

Below you will find some articles from the Department of Internal Health on "European Public Health".

They will give you a short overview whar European Public Health is about.

The department is leading in and outside Maastricht University in conceptualizing the European perspective towards health.

The following key research themes have been identified:
- Public Health in Europe
- European Integration in Public Health
- Global Health Europe

These are moderated by the processes of:
- Europeanization
- European Integration

“Public Health in Europe” describes the different Health Systems in Europe, analyses their performance, tries to find best practice solutions and how to transfer examples of good practice from one Member State to another.

“European Integration in Public Health” concentrates on European solutions of health problems which involve several Member States or are a cross cutting issue.

“Global Health Europe” looks at Europe a zone that has to interact with the outside world.

While "European Integration" describes the process of integrating states into the European Union, "Europeanization" offers the possibility to study the development of institutions of governance at the European level.

Public Health in Europe

Health Literacy in Europe

Health literacy concerns the capacities of people to meet the complex demands of health in modern society. In spite of the growing attention for the concept among European health policymakers, researchers and practitioners, information about the status of health literacy in Europe remains scarce. This article presents selected findings from the first European comparative survey on health literacy in populations. The European health literacy survey (HLS-EU) was conducted in eight countries: Austria, Bulgaria, Germany, Greece, Ireland, the Netherlands, Poland and Spain (n = 1000 per country, n = 8000 total sample). Data collection was based on Eurobarometer standards and the implementation of the HLS-EU-Q (questionnaire) in computer-assisted or paper-assisted personal interviews. Results: The HLS-EU-Q constructed four levels of health literacy: insufficient, problematic, sufficient and excellent. At least 1 in 10 (12%) respondents showed insufficient health literacy and almost 1 in 2 (47%) had limited (insufficient or problematic) health literacy. However, the distribution of levels differed substantially across countries (29–62%). Subgroups within the population, defined by financial depriv- ation, low social status, low education or old age, had higher proportions of people with limited health literacy, suggesting the presence of a social gradient which was also confirmed by raw bivariate correlations and a multi- variate linear regression model.
Limited health literacy represents an important challenge for health policies and practices across Europe, but to a different degree for different countries. The social gradient in health literacy must be taken into account when developing public health strategies to improve health equity in Europe.

Social Media and Public Health

To accomplish the aims of public health practice and policy today, new forms of communication and education are being applied. Social media are increasingly relevant for public health and used by various actors. Apart from benefits, there can also be risks in using social media, but policies regulating engagement in social media is not well researched. This study examined European public health-related organizations’ social media policies and describes the main components of existing policies.
The research used a mixed methods approach. A content analysis of social media policies from European institutions, non-government organizations (NGOs) and social media platforms was conducted. Next, individuals responsible for social media in their organization or projects completed a survey about their social media policy.
Seventy-five per cent of institutions, NGOs and platforms had a social media policy available. The primary aspects covered within existing policies included data and privacy protection, intellectual property and copyright protection and regulations for the engagement in social media. Policies were intended to regulate staff use, to secure the liability of the institution and social responsibility. Respondents also stressed the importance of self-responsibility when using social media.
This study of social media policies for public health in Europe provides a first snapshot of the existence and characteristics of social media policies among European health organizations. Policies tended to focus on legal aspects, rather than the health of the social media user. The effect of such policies on social media adoption and usage behaviour remains to be examined.

Women leadership in health care

The purpose of this paper is to map the barriers to women leadership across healthcare, academia and business, and identify barriers prevalence across sectors. A barriers thematic map, with quantitative logic, and a prevalence chart have been developed, with the aim to uncover inequalities and provide orientation to develop inclusion and equal opportunity strategies within different work environments.
A systematic literature review method was adopted across five electronic databases. Rigorous inclusion/exclusion criteria were applied to select relevant publications, followed by critical appraisal of the eligible articles. The geographical target was Europe, with a publication time range spanning the period from 2000 to 2015. Certain specialized international studies were also examined. The key themes were identified using summative content analysis and the findings were analyzed using qualitative meta-summary method to formulate hypotheses for subsequent research.
In total, 26 barriers were identified across the aforementioned sectors. A high degree of barriers commonalities was identified, with some striking differences between the prevalence of barriers across sectors.
Women’s notable and persisting underrepresentation in top leading positions across sectors reflects a critical drawback in terms of organizational and societal progress particularly regarding inclusion and balanced decision making.

Dementia in the European Union

Austerity and Health

European Integration in Public Health

Global public health challenges require stronger European collaboratio

From "Public Health in Europe" to "European Public Health"

The European Health Union: Concepts, Definition and Scenarios

The COVID-19 pandemic brought visibility and intensified the discussions on the European Union’s (EU) health mandate. The proposals of the European Commission (EC) to move towards a European Health Union (EHU) can be seen as a starting point towards more integration in health. However, the definition of what the EHU will look like is not clear. This paper searches to find a common definition, and/or features for this EHU through a systematic literature review performed in May 2021. “European Union’s concern about health for all” is suggested as a definition. The main drivers identified to develop an EHU are: surveillance and monitoring, crisis preparedness, funding, political will, vision of public health expenditures, population’s awareness and interest, and global health. Based on these findings, five scenarios were developed: making a full move towards supranational action; improving efficiency in the actual framework; more coordination but no real change; in a full intergovernmentalism direction; and fragmentation of the EU. The scenarios show that the development of a EHU is possible inside the current legal framework. However, it will rely on increased coordination and has a focus on cross-border health threats. Any development will be strongly linked to political choices from Member States.

EU Semester and Country Specific Recommendations for Health Systems

In the framework of “Europe 2020”, European Union Member States are subject to a new system of economic monitoring and governance known as the European Semester. This paper seeks to analyse the way in which national health systems are being influenced by EU institutions through the European Semester. A content analysis of the Country Specific Recommendations (CSRs) for the years 2011, 2012, 2013 and 2014 was carried out. This con- firmed an increasing trend for health systems to feature in CSRs which tend to be framed in the discourse on sustainability of public finances rather than that of social inclusion with a predominant focus on the policy objective of sustainability. The likelihood of obtaining a health CSRs was tested against a series of financial health system performance indica- tors and general government finance indicators. The odds ratio of obtaining a health CSR increased slightly with the increase in level of general Government debt, with an OR 1.02 (CI: 1.01, 1.03; p = 0.007) and decreased with an increased public health expenditure/total health expenditure ratio, with an OR 0.89 (CI: 0.84, 0.96; p = 0.001). The European Semester process is a relatively new process that is influencing health systems in the European Union. The effect of this process on health systems merits further attention. Health stakeholders should seek to engage more closely with this process which if steered appropriately could also present opportunities for health system reform.

20 years after the Maastricht Treaty

The European Union (EU) health mandate was initially defined in the Maastricht Treaty in 1992. The twentieth anniversary of the Treaty offers a unique opportunity to take stock of EU health actions by giving an overview of influential public health related EU-level policy outputs and a summary of policy outputs or actions perceived as an achievement, a failure or a missed opportunity.
Semi-structured expert interviews (N = 20) were conducted focusing on EU-level actions that were relevant for health. Respondents were asked to name EU policies or actions that they perceived as an achievement, a failure or a missed opportunity. A directed content analysis approach was used to identify expert perceptions on achievements, failures and missed opportunities in the interviews. Additionally, a nominal group technique was applied to identify influential and public health relevant EU-level policy outputs.
The ranking of influential policy outputs resulted in top positions of adjudications and legislations, agencies, European Commission (EC) programmes and strategies, official networks, cooperative structures and exchange efforts, the work on health determinants and uptake of scientific knowledge. The assessment of EU health policies as being an achievement, a failure or a missed opportunity was often characterized by diverging respondent views. Recurring topics that emerged were the Directorate General for Health and Consumers (DG SANCO), EU agencies, life style factors, internal market provisions as well as the EU Directive on patients’ rights in cross-border healthcare. Among these recurring topics, expert perceptions on the establishment of DG SANCO, EU public health agencies, and successes in tobacco control were dominated by aspects of achievements. The implementation status of the Health in All Policy approach was perceived as a missed opportunity.
When comparing the emerging themes from the interviews conducted with the responsibilities defined in the EU health mandate, one can identify that these responsibilities were only partly fulfilled or acknowledged by the respondents. In general, the EU is a recognized public health player in Europe which over the past two decades, has begun to develop competencies in supporting, coordinating and supplementing member state health actions. However, the assurance of health protection in other European policies seems to require further development.

Hospitals in the European Union

Hospitals have become a focal point for health care reform strategies in many European countries during the current financial crisis. It has been called for both, short-term reforms to reduce costs and long-term changes to improve the performance in the long run. On the basis of a literature and document analysis this study analyses how EU member states align short-term and long-term pressures for hospital reforms in times of the financial crisis and assesses the EU’s influence on the national reform agenda. The results reveal that there has been an emphasis on cost containment measures rather than embarking on structural redesign of the hospital sector and its position within the broader health care sys- tem. The EU influences hospital reform efforts through its enhanced economic framework governance which determines key aspects of the financial context for hospitals in some countries. In addition, the EU health policy agenda which increasingly addresses health system questions stimulates the process of structural hospital reforms by knowledge gen- eration, policy advice and financial incentives. We conclude that successful reforms in such a period would arguably need to address both the organisational and financing sides to hospital care. Moreover, critical to structural reform is a widely held acknowledgement of shortfalls in the current system and belief that new models of hospital care can deliver solutions to overcome these deficits. Advancing the structural redesign of the hospital sec- tor while pressured to contain cost in the short-term is not an easy task and only slowly emerging in Europe.

Structural Funds of the European Union

Making up a third of the EU budget, Structural and Investment Funds can provide impor- tant opportunities for investing in policies that tackle inequalities in health. This article looks back and forward at the 2007–2013 and 2014–2020 financial periods in an attempt to inform the development of health equity as a strand of policy intervention under regional development. It combines evidence from health projects funded through Structural Funds and a document analyses that locates interventions for health equity under the new reg- ulations. The map of opportunities has changed considerably since the last programming period, creating more visibility for vulnerable groups, social determinants of health and health systems sustainability. As the current programming period is progressing, this paper contributes to maximizing this potential but also identifying challenges and implementa- tion gaps for prospective health system engagement in pursuing health equity as part of Structural Funds projects. The austerity measures and their impact on public spending, building political support for investments as well as the difficulties around pursuing health gains as an objective of other policy areas are some of the challenges to overcome. European Structural and Investment Funds could be a window of opportunity that triggers engage- ment for health equity if sectors adopt a transformative approach and overcome barriers, cooperate for common goals and make better use of the availability of these resources.

The Public Health Directorate of the European Union

Capacity assessment has become a popular measure in the health sector to assess the abil- ity of various stakeholders to pursue agreed activities. The European Commission (EC) is increasingly dealing with a variety of health issues to coordinate and complement national health policies. This study analyses the functional capacity of the Directorate-General for Health and Consumers (DG SANCO) between 1999 and 2004. It applies the UNDP Capac- ity Assessment Framework and uses a literature review, a document review of EU policy documents and expert interviews to assess the capacity of DG SANCO to fulfill its mandate for public health and health systems. Our results suggest that DG SANCO has established capacities to engage with stakeholders; to assess various health issues, to define issue- specific health policies and to collect information for evaluative purposes. In contrast, capacities tend to be less established for defining a clear strategy for the overall sector, for setting priorities and for budgeting, managing and implementing policies. We conclude that improvements to the effectiveness of DG SANTE’s (the successor of DG SANCO) poli- cies can be made within the existing mandate. A priority setting exercise may be conducted to limit the number of pursued actions to those with the greatest European added value within DG SANTE’s responsibilities.

Joint Procurement in the European Union

The Joint Procurement Agreement (JPA) is an innovative instrument for multi-country procurement of medical countermeasures against cross-border health threats. This paper aims to assess its potential performance. A literature review was conducted to identify key features of successful joint procurement programmes. Documentary analysis and a key informants’ interview were carried out to analyse the European Union (EU) JPA. Ownership, equity, transparency, stable central financing, standardisation, flexibility and gradual development were identified as important prerequisites for successful establishment of multi-country joint procurement programmes in the literature while security of supply, favourable prices, reduction
of operational costs and administrative burden and creation of professional expert networks were identified as desirable outcomes. The EU JPA appears to fulfil the criteria of ownership, transparency, equity, flexibility and gradual development. Standardisation is only partly fulfilled and central EU level financing is not provided. Security of supply is an important outcome for all EU Member States (MS). Price savings, reduction in administrative burden and creation of professional networks may be particularly attractive for the smaller MS. The JPA has the potential to increase health system collaboration and efficiency at EU level provided that the incentives for sustained commitment of larger MS are sufficiently attractive.

Small European Member States and Health

The EU directive on patients’ rights and cross-border care is of particular interest to small states as it reinforces the concept of health system cooperation. An analysis of the challenges faced by small states, as well as a deep evaluation of their health system reform characteristics is timely and justified. This paper identifies areas in which EU level cooperation may bring added value to these countries’ health systems.
The Literature search is based primarily on PUBMED and is limited to English-language papers published between January 2000 and September 2014. Results of 76 original research papers appearing in peer-reviewed journals are summarised in a literature map and narrative review.
Primary care, health workforce and medicines emerge as the salient themes in the review. Lack of capacity and small market size are found to be the frequently encountered challenges in governance and delivery of services. These constraints appear to also impinge on the ability of small states to effectively implement health system reforms. The EU appears to play a marginal role in supporting small state health systems, albeit the stimulus for reform associated with EU accession.
Small states face common health system challenges which could potentially be addressed through enhanced health system cooperation at EU level. The lessons learned from research on small states may be of relevance to health systems organized at regional level in larger European states.

30 years after the fall of the Iron Curtain

European Health Union

Covid and the European Union

Global Health Europe

Covid-19 and International Relations: A Global Perspective

WHO and the Covid Pandemic

Antibiotic Resistance EU - India

Globally, a significant increase in the emergence of antibiotic resistant (ABR) path- ogens has rendered several groups of antibiotics ineffective for the treatment of life-threatening infections. It is an endemic in hospital settings and a major concern while handling pathogens involved in an epidemic or pandemic. ABR is a matter of great concern due to its recusant impact on public health and cost to the healthcare system, especially in developing country like India. An indiscriminate and inappropriate usage of antimicrobials, poor infrastructure and sanitation are the major factors driving the evolution of ABR in such countries. Therefore, in addition to the development of novel therapeutics and safeguarding the efficacy of existing antibiotics, there is an ur- gent need for a programme focussed on the education in risk management and prevention of ABR.
To promote qualitative teaching activities in academia and society to visualize a future where every individual is aware of ABR and empowered with right education to address the issue.
The project ‘Risk Management and Prevention of Antibiotics Resistance - PREVENT IT’, funded by the ERASMUS+ Programme of the European Union, converges academicians and non-government organizations (NGOs) to inculcate a sense of awareness towards the increase in the frequency of ABR pathogens, judicial usage of antimicrobials and the economic/health burden of ABR, in students, academicians, clinicians and population at large.
The project commissioned envisages a behavioural change in individuals and attempts to support policymakers by executing stable changes in the curricula of institutes of higher education, developing advanced workshop modules for the training of academicians and disseminating ABR-related information through conferences/seminars, social media campaigns and an online platform dedicated to ABR. In addition, the project aims to develop a European- Indian network for the management of risk and prevention of ABR.

Global Health Europe

This review attempts to analyse the global health agenda-setting process in the European Union (EU). We give an overview of the European perspective on global health, making reference to the developments that led to the EU acknowledging its role as a global health actor. The article thereby focusses in particular on the European interpretation of its role in global health from 2010, which was formalised through, respectively, a European Commission Communication and European Council Conclusions. Departing from there, and based on Kingdon’s multiple streams theory on agenda setting, we identify some barriers that seem to hinder the further establishment and promotion of a solid global health agenda in the EU. The main barriers for creating a strong European global health agenda are the fragmentation of the policy community and the lack of a common definition for global health in Europe. Forwarding the agenda in Europe for global health requires more clarification of the common goals and perspectives of the policy community and the use of arising windows of opportunity.

International Health Regulations

The revised World Health Organization’s International Health Regulations (2005) request a timely and all-hazard approach towards surveillance, especially at the subnational level. We discuss three questions of syndromic surveillance application in the European context for assessing public health emergencies of international concern:
(i) can syndromic surveillance support countries, especially the subnational level, to meet the International Health Regulations (2005) core surveillance capacity requirements, (ii) are European syndromic surveillance systems comparable to enable cross-border surveillance, and (iii) at which administrative level should syndromic surveillance best be applied?
Despite the ongoing criticism on the usefulness of syndromic surveillance which is related to its clinically nonspecific output, we demonstrate that it was a suitable supplement for timely assessment of the impact of three different public health emergencies affecting Europe. Subnational syndromic surveillance analysis in some cases proved to be of advantage for detecting an event earlier compared to national level analysis. However, in many cases, syndromic surveillance did not detect local events with only a small number of cases.
The European Commission envisions comparability of surveillance output to enable cross-border surveillance. Evaluated against European infectious disease case definitions, syndromic surveillance can contribute to identify cases that might fulfil the clinical case definition but the approach is too unspecific to comply to complete clinical definitions. Syndromic surveillance results still seem feasible for comparable cross-border surveillance as similarly defined syndromes are analysed.
We suggest a new model of implementing syndromic surveillance at the subnational level. In this model, syndromic surveillance systems are fine-tuned to their local context and integrated into the existing subnational surveillance and reporting structure. By enhancing population coverage, events covering several jurisdictions can be identified at higher levels. However, the setup of decentralised and locally adjusted syndromic surveillance systems is more complex compared to the setup of one national or local system.
We conclude that syndromic surveillance if implemented with large population coverage at the subnational level can help detect and assess the local and regional effect of different types of public health emergencies in a timely manner as required by the International Health Regulations (2005).