Public health was at the top of national and international political agendas during the COVID-19 pandemic. The successful joint procurement of vaccines and evident value of cross-border cooperation on health issues inspired institutions to propose a European Health Union (EHU). While EU health-related legislation has existed since the 1980s, healthcare systems had remained the responsibility of member states. The EHU, initially focused on international health threats, pandemic preparedness, and disease surveillance, would create greater trans-national cooperation. 

Integrating health issues     

“We started talking about the idea of a health union half a decade ago,” says Dr Milka Sokolović, Director General of the European Public Health Alliance. But discussions tend to be limited to sickness and healthcare products and services. We should not stop there, because health is way more than managing disease.” 

Initiatives under the EHU include extending mandates of the European Medicines Agency and the European Centre for Disease Prevention and Control, setting up the Health and Emergency Response Authority, and reforming pharmaceutical legislation. “This mirrors the way health is dealt with legally and institutionally at the EU level,” explains Sokolović, “but it doesn’t fully reflect the potential synergies of increased focus on health as a cross-cutting issue.”  

The EHU also proposes initiatives for cancer prevention and mental health promotion, which is particularly welcome, as these areas are largely underfunded. Prior to the pandemic, only around 3 per cent of health spending in EU and OECD countries was allocated to prevention. Meanwhile, an estimated 70-80 per cent of health budgets in EU countries is spent treating chronic diseases. Around 700 billion euros fund the treatment of mostly preventable, lifestyle-related diseases; at least 80 per cent of all heart disease, strokes, and diabetes, and around 40 per cent of cancers could be prevented by applying the right prevention procedures.  

The OECD has made the economic case for investing in disease prevention and tackling risk factors for many years. Currently, 20 per cent of the 5.3 billion euros budget of the recently established EU4Health funding programme is allocated to health promotion and disease prevention. However, tackling risk factors also means prioritising public health outcomes in policy areas other than health.  

Tackling risk factors also means prioritising public health outcomes in policy areas other than health.

“We have to recognise that some of our policies – in areas such as social, employment, finance, and trade – are health-harming and out of line with the ambitions of the EU”, says Sokolović. She identifies the lack of binding, Union-wide rules to limit food marketing targeting children, despite obesity affecting one in three children in Europe. In addition, she is concerned about delays to legislation, including the REACH Regulation (aimed at limiting the health and environment impacts of chemicals), initiatives for sustainable food systems, and laws on mandatory alcohol labelling. “Integrating public health priorities in these files is challenging,” says Sokolović, “largely due to the imbalance of power between civil society representatives and major pressure brought by the vested interests of industry.”  

Elizabeth Kuiper, Associate Director and Head of the Social Europe and Well-being Programme at the European Policy Centre sees the EHU as a step in the right direction to “pave the way for further integration in the field of health and evolve over time to address health issues in the broadest sense.”  

In a recent discussion paper, co-authored with Danielle Brady, Kuiper recommends, among other things, appointing a vice-president for well-being focused on adopting a more holistic approach to health, strengthening the implementation of health in all policies, and promoting stronger links between the EHU and the European Green Deal to ensure planetary health.      

The Well-being Economy  

Many of these ideas are central to the concept of a well-being economy, an alternative to GDP, whereby societal progress could be assessed through multiple outcomes concerning people, the planet, and future generations.   

Chris Brown, Head of the World Health Organisation (WHO) European Office for Investment for Health and Development, a leading figure in the movement for a well-being economy sets out the need for equality: “It’s basically an approach about making the economy work for everyone, so that all people can thrive and prosper in good times and in crises,” she says. “We’re seeing growing inequalities as a consequence of focusing on profit maximization above everything else, and it’s clear that the market economy is failing to deliver on a number of basic public goods.”  

Chief among these collective goods is health. WHO/Europe, via Brown’s office, is convening a wider range of partnerships to encourage countries to adopt economies of well-being that position health centrally. The initiative addresses adverse health outcomes such as the 600,000 deaths during the pandemic linked to underinvestment in health systems, and the current mental health crisis among young people. “GDP is part of a global economic system that’s used to measure development,” says Brown. “But it’s not really a good indicator for measuring societal progress, and it doesn’t really tell us how healthy that society is.” When up to 40 per cent of people are struggling to pay bills and heat their homes even in high-income countries, notes Brown, inequity leads to distrust in governments and institutions, compromising the rule of law and the social contract. “The well-being economy recognizes that good quality, basic public goods – such as food, shelter, clean water, transport – must be made available and that requires more than tagging on market regulations.” 

Recent examples of the well-being economy gaining traction in policymaking, include: a WHO/Europe resolution in 2019; the 2019 European Council conclusions inviting member states to incorporate well-being into their governance structures; the recommendations of the Pan-European Commission on Health and Sustainable Development in 2021, and in 2022 the inclusion of well-being in the objectives of the Environment Action Programme to 2030.  

Lisa Hough-Stewart, Implementation Lead at the Wellbeing Economy Alliance (WEAll), a broad coalition of civil society stakeholders advocating for economic transformation, has witnessed a recent upsurge of interest in the well-being economy from activists, trade unions, academia, and policymakers. She cites the Beyond Growth conference, co-organised by WEAII in May 2023, as a pivotal moment: “It was amazing to see the level of engagement, especially from members of the European Parliament from across the political spectrum, in conversations that weren’t possible five years ago.” The pandemic, in Hough-Stewart’s opinion, enabled many people to question their personal values about success, in turn leading to a re-evaluation of and interest in changing the current economic system.  

A central WEAll mission is challenging established narratives about prosperity and the presentation of political choices as trade-offs. Examples include combating the “health versus wealth” and “lives versus livelihoods” framing of public health restrictions on movement during the pandemic. Research shows that the very narrative about this idea of trade-off between health and the economy actually undermined the effectiveness of COVID-19 responses around the world,” says Hough-Stewart. “The idea that countries could only save their economies or save lives has been proved false. There has been no trade-off between the economy and health since March 2020: either countries have preserved both, or they have hurt both. Protecting public health first and foremost means more resilient societies and this supports the economy.” 

Climate x Health = One Health  

The public health community is increasingly vocal on the lack of progress in reducing global greenhouse gas emissions; it is significant that health was prominently featured for the first time at the annual global climate summit (COP28).  

Climate change is altering environmental conditions and this is leading to serious impacts on human health.

“It’s clear that climate change is altering environmental conditions and this is leading to serious impacts on human health,” says Tilly Metz, member of the European Parliament (Greens/EFA) and Vice-Chair of the European Parliament’s Subcommittee on Public Health (SANT). She describes climate change as a health-threat multiplier, causing excess deaths through heat stress, placing pressure on food systems and food security, affecting both crop volume and nutrient quality, threatening fragile supply chains in the global food system, and increasing the likelihood of zoonotic disease and the prevalence of vector-borne diseases. “These are just some of the many aspects where it’s clear that we need to think in a holistic way, and consider the links between human health and the health of our natural environment,” says Metz. “Although it’s currently far from mainstreaming, we do need a paradigm shift to an economy of well-being, an approach that looks beyond GDP.”  

Metz sees plenty of scope for integrating health into wider policymaking, including the EHU. “The current legislative set-up designating health as a member-state competence should not be used as an excuse for failure to act on health at the EU level,” she says. “It’s not an argument for doing nothing. I fully support the proposal for a vice-president for well-being, and the EHU is also an opportunity for us to further holistic approaches like One Health,” adds Metz, noting the establishment of a One Health directorate under DG SANTE, the branch of the European Commission responsible for health and food safety policies, and the recent statement by five EU agencies on their joint commitment to fully supporting the One Health agenda in Europe.  

Such signs are encouraging, but more concrete policy actions are needed to fully operationalise these concepts, along with fundamental economic reform. Citing agricultural policy and pharmaceuticals legislation as two examples where such reform is needed, Metz says: “We have to change the way we do business in a number of areas in order to stop environmental harm and pollution and to promote health. We see these issues cropping up everywhere, but economic reform is very difficult, as the discussion around ending fossil fuel subsidies shows. Security – in terms of war, energy security, food security – is a leading issue right now and, in that political mood, there can be a lot of fear and unwillingness to change.”