Policy instruments used by the EU to govern trade in goods also apply to services, but the latter are shaped by the General Agreement on Trade in Services (GATS) as well

Trade agreements: The EU seeks to speak with ‘one voice’ in trade negotiations with third countries, giving it more leverage in trade negotiations than individual Member States would have alone. This is important for health because the way in which the EU incorporates core values, such as sustainable development, into its trade policy can influence practice in other countries. Chapters on trade and sustainable development (TSD) incorporated by the EU in its trade agreements, combined with diplomatic activities designed to improve compliance with agreements, have the potential to improve sustainability and health in both the EU and trading partner countries.

Trade arrangements: The EU also takes many unilateral trade policy actions that have the potential to affect health in third countries. Several types of trade arrangement offered by the EU grant non-reciprocal, preferential terms of trade to third countries in order to influence the trading relationship in line with EU core values. The Generalised Scheme of Preferences (GSP)+, for example, aims to promote sustainable development and good governance in developing countries by offering advantages above and beyond the standard GSP. Third countries obtain trade benefits for complying with international agreements and conventions on human rights, labour rights, environmental protections and good governance. Everything But Arms removes tariffs and quotas on goods except arms and ammunition for least developed countries (LDC).

Box 6

Transversal topics.

Consultation mechanisms: The EU Commission routinely consults with the public, Member States (in the form of expert groups), stakeholders and civil society groups when deciding upon and implementing trade policies, although global health issues are not frequently the focus of these consultations. The Civil Society Dialogue (CSD) provides a formal channel for information sharing and relationship building with civil society groups which goes beyond the ad hoc consultation mechanisms adopted by many other countries (Velut et al., 2022). The CSD aims to ensure that trade agreements are implemented in ways that do not run counter to the EU’s core value of sustainable development. DG TRADE also consults with civil society groups in third countries about the implementation of trade agreements through domestic advisory groups. Compared to major trading partners such as the United States, the CSD provides unusually strong representation for civil society, but civil society engagement is often too late in the process and the process does not allow it to counterbalance traditionally dominant business interests.

Trade defence: The European Commission also has the ability to use various policy instruments to defend EU interest groups against trade distortions and non-compliance with the content of trade agreements. Use of trade defence measures occurs after investigation by DG TRADE and requires specific evidence about the trade distortion. Most defence complaints relate to technical trade matters. But, as of June 2022, EU stakeholder groups can raise issues of systematic non-compliance with TSD chapters or the GSP via the Single Entry Point, a single point of contact within DG TRADE designed to expedite complaints (European Commission Directorate-General for Trade, 2022). The definition of stakeholders is quite broad and includes Member States, businesses, industry and employer associations, trade unions, NGOs (including foreign organizations participating in domestic advisory groups), EU citizens and permanent residents.

Policy reviews: In order to set a future strategic direction, the EU conducts regular reviews of its trade policy. The most recent review, ‘Trade policy review – an open, sustainable and assertive trade policy’, was published in February 2021 (European Commission, 2021a). The 2021 review envisions three core principles behind EU trade policy: the green and just transition, openness and assertiveness. The review also notes the importance of trade in health-related products in the context of the COVID-19 pandemic, where heightened demand and supply constraints came together to expose vulnerabilities in the health sector. Understanding and addressing such supply-chain issues, which have implications for health outcomes in both EU Member States and third countries, is an important part of supporting global health. In June 2021, the Commission also launched a ‘Trade and Sustainable Development Review’ with the aim of strengthening the contribution of EU trade agreements to sustainable development. In its Communication presenting its conclusions from the Review, the Commission states its support for including occupational safety and health in future TSD chapters, in line with a recent expansion of the International Labour Organization (ILO)’s core principles (EUR-Lex, 2022).

Trade in services: Many of the policy instruments used by the EU to govern trade in goods also apply to trade in services. However, policies governing trade in services are construed slightly differently, shaped by the WTO’s GATS. Under the GATS, countries agree to shape the regulation of trade in services within their domestic borders in certain sectors only. Countries may also include limitations to the liberalization of services trade in their specific schedules. Such limitations on trade in health services have been a matter of much debate within the EU.

The GATS covers four modes of supply in which WTO members may choose to make commitments: cross-border supply of services; consumption abroad; commercial presence; and presence of natural persons. In the health care sector, these could correspond, for example, to the cross-border supply of health care in a country by a non-resident provider, the ability for the residents of one country to purchase health services within another country, a commercial health care provider establishing, operating or expanding health care provision in another country, and medical professionals moving to another country to provide health care services.

Negotiations on trade in services and domestic regulations are ongoing within the WTO. In 2021, a group of 67 WTO members, including the EU, announced the conclusion of the Joint Initiative on Services Domestic Regulation, which aims to “simplify unnecessarily complicated regulations and ease procedural hurdles faced by SMEs in particular”. Because women entrepreneurs are an important part of the small and medium-sized enterprise (SME) sector, the agreement includes a novel binding provision on non-discrimination between men and women. Participants in the Joint Initiative are expected to finalize their schedule of specific commitments to facilitate trade in services within their markets by the end of 2022. Pre-finalization commitments for the EU have been formulated, although the documentation is not currently public.

As the largest contributor of Aid for Trade, the EU provides significant technical assistance and other support to low-income countries

Aid for Trade: The EU and its Member States constitute the largest contributor of Aid for Trade (AfT) worldwide, providing 38% of global AfT. The EU’s AfT activity, in line with the WTO AfT initiative, provides technical assistance, capacity building, budget support, blending (combining EU grants with loans or equity from public and private sources), and guarantees to provide support in areas including agriculture, energy infrastructure, transportation, and banking and financial services. Aid for Trade also includes the preferential trading arrangements offered to low-income countries outlined above, such as GSP+ and Everything But Arms. In line with the 2017 Joint EU Strategy on Aid for Trade, the EU aims to increase the proportion of AfT provided to LDCs from 15% to 25% by 2030 in order to improve their share of global exports (EUR-Lex, 2017).

The EU conducts assessments and evaluations that seek to understand the impacts of its potential and existing trade policies

Analysis and assessment: The EU conducts, and contracts with outside parties to conduct, a variety of assessments and evaluations that seek to understand the impacts of its potential and existing trade policies. While some of these assessments are primarily focused on economic impact, others consider EU core values such as sustainable development. Sustainability impact assessments (SIAs) include assessment of social, environmental and human rights issues related to ongoing trade negotiations. SIAs aim to further the goals outlined in the EU’s Better Regulation Agenda, promoting transparency in regulation and centring consultation with civil society. The EU has a very mixed record on using impact assessments and the SIAs’ impact for sustainability and health could probably be much greater.

Box 7

Stakeholders remain divided on the question of balancing intellectual property rights and access to medicines.

The Global Gateway lies at the heart of the EU’s global investment strategy and comprises instruments of relevance for global health

The Global Gateway lies at the heart of the EU’s global investment strategy. It was announced in 2022 and is expected to facilitate global infrastructure development, including health infrastructure, and to mobilize up to 300 billion euros in investment worldwide between now and 2027. This investment spur will be catalysed by leveraging financial support from a range of EU instruments, including Global Europe, the Instrument for Pre-accession Assistance (IPA III), Interreg, InvestEU and the Connecting Europe Facility (European Commission, undated, a). Most of these instruments are scattered across different policy areas, including areas that are relevant for global health in their own right, such as the EU’s development, neighbourhood and enlargement policies. For this reason, tools such as Global Europe and IPA III are presented in further detail in subsequent sections of this policy brief, which discuss these respective policy areas. Others, like InvestEU, Interreg and the Connecting Europe Facility, are instruments primarily dedicated to investment in infrastructure and are therefore outlined in further detail here. Although it is not strictly part of the Global Gateway and it places a stronger focus on health initiatives for knowledge sharing and collaboration, EU4Health also provides funding for a range of relevant initiatives and is therefore featured here. Some of these instruments feature specific funding for non-EU countries, while others focus on European investment streams that may have spillover effects on other areas of the world. In addition, the new Global Health Strategy highlights the EU’s plans to explore the use of innovative financial instruments, including debt swaps and loan buy-downs, to trigger further investment for health systems in third countries (European Commission, 2022b).

Box 8

The EU–Africa Global Gateway Investment Package includes health system strengthening among its areas of focus (European Commission, undated, d).

EU-funded projects can pursue diverse aims in the area of health, relevant to EU Member States, accession and other countries

Connecting Europe Facility

The Connecting Europe Facility (CEF) is an instrument with a total budget of just over 30 billion euros (of which 1.6 billion are dedicated to its Digital stream; other streams include Transport and Energy but are less relevant to this policy brief), which aims to improve connectivity and boost digitalization across the EU (European Climate Infrastructure and Environment Executive Agency, undated; European Health and Digital Executive Agency, undated). Although it is currently mostly being used to support projects within the EU, it may have relevant spillover effects in surrounding regions. For example, the establishment of cross-border cloud infrastructure interconnections may extend to and improve digital health facilities in third countries (European Health and Digital Executive Agency, undated). Similarly, the digital stream of the Global Gateway strategy foresees CEF-funded deployment of transcontinental backbone networks, such as satellites and submarine cable connections, to strengthen the connectivity between the EU and other regions of the world (European Commission, 2022f). This is likely to substantially improve internet connectivity and possibly facilitate remote health services like telemedicine consultations across continents.

Box 9

Transversal topics.

ODA is a shared competence between the EU and Member States; jointly they are the largest donor of ODA worldwide

Official development assistance is a competence shared between the EU and its Member States. Consequently, most Member States have their own bilateral development programmes in addition to their participation in EU development policies and the multilateral commitments made at EU level (Steurs et al., 2018). In 2021, the EU and its Member States jointly donated 70.2 billion euros, accounting for 43% of global development assistance and representing the largest donor of ODA worldwide (Council of the European Union, 2022).

Health has been an important component of the EU’s development assistance, with the approach changing over time from disease-specific programmes to more comprehensive health systems strengthening

Health has long been considered an integral component of the EU’s development assistance. Particularly since the early 2000s, development assistance for health has increased, with large streams of funding flowing into a range of global initiatives born at the turn of the millennium, such as the Global Fund dedicated to fighting acquired immunodeficiency syndrome (AIDS), tuberculosis and malaria, and the Global Alliance for Vaccines and Immunisation (Hafner and Shiffman, 2013). Over time, there has been a gradual shift in interest from initiatives primarily focused on disease-specific programmes to more comprehensive health system strengthening (HSS) approaches in donor countries. Reasons for this have included, amongst others, concerns over slow progress in achieving health-focused millennium development goals (MDGs) (Hafner and Shiffman, 2013).

Advising the planning of the EU’s development policy and the programming of its primary financial tools, is the European Consensus on Development, a statement which was first undersigned in 2005 and later renewed by the Council, Parliament and Commission in response to the adoption of the 2030 Agenda for Sustainable Development by the United Nations in 2015 (United Nations, 2015; Council of the European Union, 2017). This document outlines the EU’s strategic priorities and frames the common approach taken by Member States at the EU level with the aim of ensuring complementarity and coordination with their national development activities. The Consensus places a focus on five key themes, the so-called 5 Ps, which reflect the priorities expressed in the UN 2030 agenda and the concomitant SDGs: people, planet, prosperity, peace and partnership (Council of the European Union, 2017). Health is explicitly discussed as a dimension of the EU’s development efforts with a list of dedicated goals, the pursuit of which forms part of a comprehensive Health in All policies approach (see Box 5 for more information on Health in All policies).

Key objectives with a focus on health include supporting:

• health system strengthening, better access to services and UHC
• health workforce training, professional development, recruitment and deployment
• investing in frontline health care and social workers for delivery of care in underserved and isolated areas
• prevention and treatment of communicable diseases including human immunodeficiency virus (HIV)/AIDS, tuberculosis, malaria and hepatitis, as well as epidemic outbreaks and AMR
• addressing chemical pollution and poor air quality
• prevention and treatment of non-communicable diseases, including mental health and further reducing child and maternal mortality rates.

While support for disease-specific interventions continues to be provided through initiatives like the Global Fund (described earlier in this section), the document highlights the need to move towards more horizontal and cross-sectoral approaches. The Consensus describes numerous other areas of action with a direct relevance for global health, including efforts to strengthen social protection mechanisms and to achieve better gender equality, for instance through access to sexual and reproductive health care, or to enhance access to clean water and sanitation facilities for underserved populations, thereby contributing to the fight against infectious diseases. The EU continues to establish the importance of equitable care, as seen in Guiding Principles 1 and 2 of the EU Global Health Strategy, which aims to integrate various stakeholders into the mission to fight existing inequities in care (European Commission, 2022b).

Beyond global development and diplomacy efforts, the EU’s foreign policy has also pursued distinguished priorities in its immediate neighbourhood through a dedicated Neighbourhood Policy, which currently applies to the 16 closest countries to the east and south of the EU and is delivered through the Eastern² and Southern³ neighbourhood partnerships. The EU’s Neighbourhood Policy, which was reviewed in 2015, is focused on promoting the political, social and economic stability of its closest neighbours, including promoting good governance, rule of law and strengthening human rights (including access to health care) (European Commission, undated, g).

Priorities for the ongoing programming cycle include investing in the modernization of medical facilities and digital infrastructure, workforce training and improving access to health services and social protection systems, as well as bolstering preparedness and response capacities and setting up an EU vaccine-sharing mechanism (European Commission & High Representative of the Union for Foreign Affairs and Security Policy, 2020, 2021).

Another group of countries endowed with a special status are those in the EU’s enlargement region,⁴ which receive additional financial and technical support tailored towards meeting the requirements for EU entry. This entails the adoption of all EU laws (acquis communautaire) and standards, including in the area of health (Greer et al., 2022b) (see Box 10 for further information). Financial support is delivered via the Instrument for Pre-accession Assistance (IPA III, MFF 2021–2027). IPA III has a budget of 14.16 billion euros for the financial period 2021–2027 and has been particularly instrumental to health during the COVID-19 pandemic, funding the provision of vaccine doses and activities to strengthen health system surveillance capacities (European Commission, 2022g). For example, within the scope of IPA III, a pre-accession support package worth 70 million euros was signed with Serbia in 2020 to support its development, but also to strengthen the country’s recovery and preparedness and response capacities for managing infectious diseases in the future (European Commission, 2020a).

Box 10

EU accession candidates and neighbourhood receive financial and technical support towards adopting EU standards in the area of health.

Starting with the EU’s new MFF, most of the instruments used to implement these policies and strategic priorities (including the former European Development Fund (EDF) and ENI) have come together under a single umbrella instrument called Global Europe for the first time. Global Europe covers all EU funding for cooperation with third countries⁵ and unifies the financial tools dedicated to neighbourhood, development and international cooperation (NDICI) policies with a budget of 79.5 billion euros for the period 2021–2027 (European Commission, undated, l). Within the European Commission, which is in charge of administering and implementing instruments like NDICI–Global Europe, there are two main Directorates General responsible for putting into action the EU’s development and neighbourhood policies: the Directorate General for International Partnerships (DG INTPA) and the Directorate General for Neighbourhood and Enlargement Policy (DG NEAR).

The commitment to human development outlined in the European Consensus on Development is reflected in DG INTPA’s strategic plan for 2020–2024, which governs how available financial instruments like Global Europe will be implemented. For example, the plan pledges at least 20% of funding from Global Europe towards human development initiatives. As highlighted above, health is considered to be a crucial dimension of human development. An important part of the funding dedicated to health is reserved for GAVI and the Global Fund, and monitored through performance indicators like child immunization and coverage of modern contraceptive methods. However, several other projects relevant to strengthening health systems and improving health are being funded by Global Europe and its predecessor programmes (see Table 1 for examples of funded projects) (European Commission, undated, m).

Last but not least, an important component of the EU’s development policy relates to its participation in global partnerships. These include the Global Partnership for Effective Development Cooperation, which brings together multiple stakeholders including governments and multilateral organizations, to work together on enhancing the effectiveness of international development cooperation. Further partnerships include the UHC Partnership and UHC 2030 aimed at coordinating efforts across a range of different public and private sector stakeholders to achieve UHC and strengthen health systems globally. Further information on the EU’s involvement in multilateral cooperation and collaborative forums is provided in the section ‘Solidarity, voice and multilateralism’.

Global Europe is an umbrella instrument that unifies financial tools dedicated to neighbourhood, development and international cooperation

Global Europe: NDICI

(European Commission, undated, l)

Global Europe is a new comprehensive instrument made up of three pillars:

• The geographical pillar provides support that is tailored to the specific needs of different regions, countries and local contexts. Its overall budget of 60.39 billion euros is distributed across the neighbourhood countries (19.32 billion), as well as countries in Sub-Saharan Africa (29.18 billion), Asia and the Pacific (8.49 billion) and the Americas and Caribbean (3.39 billion).
• The thematic pillar, which zooms in on specific issues, provides dedicated funding of 6.36 billion euros for human rights and democracy, strengthening civil society, promoting stability and peace, and addressing specific global challenges, such as health, education, social protection and supporting marginalized populations including migrants, women and children.
• Lastly, the rapid response pillar reserves 3.18 billion euros for unexpected events that require immediate interventions, such as crisis response and conflict prevention.

Box 11

Global Europe’s 2021–2027 thematic multiannual indicative programme aims to address global challenges and is especially relevant to advancing health and global health priorities (European Commission, 2021b).

Other features of this new instrument include a flexibility cushion of 9.53 billion euros, which permits allocation of resources to unanticipated and new challenges, as well as an investment framework, which enables additional funds to be raised and mobilized from public and private sector investment. The latter entails the European Fund for Sustainable Development Plus (EFSD+), a successor programme to the European Fund for Sustainable Development (EFSD), which is backed by a budget guarantee of 53.45 billion euros, the External Action Guarantee. This instrument provides a set of financial mechanisms including loans, grants and guarantees to support potential investors by sharing the risk of investing and providing the financial backing needed to support sustainable development in those partner countries with more unstable markets or investment conditions (European Commission, 2021c). The EFSD+ also represents the main financial tool for raising global investments as part of the overarching Global Gateway Strategy (see section on ‘Public investment’). In addition to the above-mentioned financial mechanisms, the EU offers partner countries budget support, which consists of the direct transfer of funds to their national treasuries. This type of support is available to countries that are investing in national reforms to strengthen their public institutions and in capacity development aimed at achieving SDGs (see examples of projects financed with budget support, predecessor programmes such as the EFSD and the EDF, and other Global Europe streams in Table 1 below) (European Commission, 2021d).

The primary aim of technical assistance is to strengthen the institutions and public authorities which administer funds and implement reforms in the recipient countries; such assistance has been used to propel reforms and build capacity in the health sector

The EU’s commitment to third countries is not limited to financial aid and investment. Technical assistance represents another component of the relationship and is delivered through a range of instruments tailored to the specific needs of different geographical regions. Their primary objective is to strengthen the institutions and public authorities that administer financial instruments like Global Europe and implement the reforms needed to move towards the SDGs. For instance, the Twinning instrument was specially developed to assist public administrations of EU accession candidates and countries in the neighbourhood with adopting EU legislation (Union acquis), as well as strengthening capacity and building institutional expertise. Support is delivered through peer-to-peer activities, such as workshops, training, study visits and expert missions involving public administration representatives (European Commission, undated, k). Another instrument, which can also be applied to countries outside the direct neighbourhood is called Technical Assistance and Information Exchange instrument (TAIEX-INTPA). This form of technical support entails peer-to-peer assistance with implementing structural reforms and development policies, and is provided to both public administrations and a range of other authorities, including law enforcement, trade unions and employers’ associations. Both instruments have been used to propel public health reforms and to ensure local administrative structures develop the necessary capacities to meet the health standards required to be considered for EU membership (European Commission, undated, j). Capacity building is also extended to the health workforce through programmes like the Mediterranean and Black Sea Programme for Intervention Epidemiology Training (MediPIET), which provides training for field epidemiologists, and contributes towards boosting knowledge sharing and regional cooperation in the Mediterranean region (ECDC, 2022b).

Table 1

Examples of relevant initiatives funded by Global Europe and its predecessor programmes (EDF, EFSD).

Box 12

Transversal topics.

The EU supports third countries in times of crisis and humanitarian disasters

In times of crisis and in the face of humanitarian disasters, the EU supports third countries through dedicated mechanisms overseen by the European Commission’s Directorate General for European Civil Protection and Humanitarian Aid Operations (DG ECHO). As the largest donor of aid in the world,⁶ the EU funds humanitarian aid projects on the ground, as well as pooling and deploying experts to support local response and recovery efforts in the aftermath of a crisis (United Nations Office for the Coordination of Humanitarian Affairs, 2022; European Commission, undated, n). To effectively implement the latter, DG ECHO also operates the EU Civil Protection Mechanism, which pools resources from the EU and other participating countries⁷ for a collective response to disasters and a coordinated transport of supplies and experts to affected regions worldwide.

Beyond providing immediate help, the EU’s humanitarian action also focuses on strengthening preparedness and response capacities

EU humanitarian action pursues three main objectives: to preserve life; to prevent and alleviate human suffering; and to maintain human dignity. The European Consensus on Humanitarian Aid is the policy statement (undersigned by the Member States, the Commission, the Parliament and the Council), which sets out a common vision and shapes the EU’s action framework since 2008 (EUR-Lex, 2008). The principles outlined in the Consensus were reaffirmed in the 2021 Commission Communication on the EU’s humanitarian action, which discusses the impact of and updates the actions proposed to respond to new challenges such as COVID-19, and climate change- and conflict-induced emergencies (European Commission, 2021f).

Beyond securing and deploying essential medical supplies, an important aspect of the EU’s humanitarian action in the area of health entails strengthening preparedness capabilities and building up the capacity of fragile environments to respond to future crises. The role of multilateral engagement and the recognition of competent UN agencies and NGOs as key interlocutors and implementers in the field is equally central to the EU’s humanitarian aid philosophy. At the same time, the experience gained during the COVID-19 pandemic with initiatives like the EU Humanitarian Air Bridge (HAB) operations (see Box 13 for further information), which saw a direct engagement of the EU in the countries in need, has paved the way for a stronger EU involvement on site. Plans to build a European Humanitarian Response Capacity (EHRC), which now enables direct intervention and expands the delivery of humanitarian aid on the ground, were outlined in the 2021 Communication mentioned above. Further priorities highlighted in the Communication include increasing the flexibility of funding mechanisms and improving the continuity between humanitarian and development instruments to better face upcoming challenges and facilitate a territory’s longer-term recovery in the aftermath of a crisis.

The Civil Protection Mechanism was established in 2001 to mount collective and coordinated responses to natural and anthropogenic disasters in the EU and countries participating in the mechanism. In case of need, countries can seek assistance from the mechanism’s coordinating centre, the Emergency Response Coordination Centre, which assembles the required support by connecting with civil protection authorities at national levels and subsequently coordinates the rollout of assistance, including teams of EU civil protection experts. Although primarily dedicated to helping participating countries, any country or organization (including UN agencies and other humanitarian organizations) can request assistance in case of emergency (European Commission, 2022l). In this context, EU humanitarian aid and civil protection frequently aim to function together through complementary efforts.

Humanitarian aid budgets support recovery from COVID-19

DG ECHO manages two separate budgets for humanitarian aid and the EU Civil Protection Mechanism, the latter having been allocated a total 3.3 billion euros for the next seven years (European Commission, 2022m). In turn, financing for humanitarian aid is decided upon on an annual basis, with a budget of 1.7 billion euros allocated to this cause for 2023 (European Commission, 2023c). The ongoing financial cycle (MFF 2021–2027) has seen both portfolios increase considerably compared to past iterations as a result of the temporary budgetary boost provided through new instruments like NextGenerationEU conceived to support the recovery from COVID-19. In addition, the Solidarity and Emergency Aid Reserve (SEAR) merges two instruments of reserve funding, which can be requested in case of unforeseen emergencies and crises prompting an EU-level response, including public health emergencies (European Commission, undated, o).

The primary objective of these financial instruments is to deliver humanitarian aid to populations affected by natural and anthropogenic disasters, including delivering an immediate response after the occurrence of such an event (an example of this being the EU Humanitarian Air Bridge in Box 13) and developing longer-term support systems and coping strategies in fragile environments. Amongst other things, funding in 2022 was made available for activities pertaining to disaster risk reduction and preparedness, and the establishment of the EHRC (mentioned above). Since its inception, the EHRC has been instrumental in supporting the humanitarian response in Ukraine (see Box 13). Directly related to health, there is earmarked funding for epidemiological support provided by ECDC in the event of significant pandemic outbreaks (such as Ebola, COVID-19 or other diseases of equivalent severity). There are also plans to establish an EU Health Task Force at the ECDC to work closely with DG ECHO on strengthening country preparedness and to mobilize a coordinated response in the case of future health emergencies (Council of the European Union, 2021a).

Box 13

EU Humanitarian Air Bridge as a prime example of humanitarian aid during COVID-19 and the conflict in Ukraine.

Medical reserves and capacity-building activities support crisis response in countries participating in the Civil Protection Mechanism and beyond

The European Civil Protection Pool collects ready-to-deploy resources from Member States and countries participating in the European Civil Protection Mechanism for immediate intervention and crisis response. As part of this pool, the Emergency Medical Corps mobilizes various types of medical reserves that have been pledged by EU Member States to the European Civil Protection Pool. Support provided includes workforce, such as health care experts and emergency medical teams deployable at short notice, as well as mobile biosafety laboratories and medical evacuation facilities, which may be distributed to territories affected by a health emergency. The Medical Corps was called into life after the Ebola epidemic in West Africa in 2014 and continues to participate in missions. For example, a measles outbreak in 2019 saw the deployment of emergency medical teams to Samoa to support the local response efforts (European Commission, 2021g). Deployment of medical teams is coordinated by the Emergency Response Coordination Centre, the operational heart of the Civil Protection Mechanism.

Also available to all Member States, the countries participating in the Civil Protection Mechanism, and Enlargement and Neighbourhood countries, there is another technical instrument called the Peer Review Programme, which enables national civil protection authorities to assess their readiness to respond in a crisis and to identify gaps for improvement and bolstering of capacities. Throughout the readiness review process, a selection of experts from other participating countries produce a report which features context-specific recommendations for the country being analysed. In addition, the programme provides an opportunity for mutual learning and exchange of best practices across competent authorities (European Commission, undated, p).

While the EU plays a significant role in shaping global health policies, many of the Member States also pursue their own objectives on a bilateral level

While the EU plays a significant role in shaping global health policies, many of the Member States also pursue their own objectives on a bilateral level. Some Member States, such as Germany and France, have devised national global health strategies over the past decade (European Commission, 2021h; and see Steurs et al., 2017 for concrete examples). These bilateral relationships are important but can also be a source of tension between the Member States and the EU in case of diverging priorities and the possible duplication, or worse, fragmentation of efforts at national and union levels. The Strategy highlights the need to build purposeful synergies with all Member States, including pursuing upstream coordination with those countries that are not equally represented among multilateral forums such as the G7 or the G20 (European Commission, 2022b).

As highlighted in ‘Official development assistance and humanitarian aid’, Team Europe includes the EU, its Member States, the EIB and EBRD and, since its creation in 2020 as a response to the COVID-19 pandemic, aims to improve the coordination and coherence efforts between partners (European Commission, 2023d). The primary goal is to make a sustainable recovery through building back better whilst achieving the SDGs through multilateral cooperations. In theory, the Team Europe initiative is a replacement for the former ‘flagship initiatives’ (WHO, undated, a) and can be formed at the country level or the regional level. The initiatives, however, must link to the priorities laid out in the MIPs (see European Commission, undated, m, for examples), which are directly linked to the global priorities of the EU. A practical example of how Team Europe has demonstrated a common EU voice can be found in the COVAX initiative.

Box 14

ACT-A AND COVAX brought together stakeholders in the fight against COVID-19.

The EU plays an important role in influencing the G7 agenda

The EU is a non-enumerated member of the G7 and thus does not participate in the rotating presidency; however, it plays an important role in influencing the G7’s agenda. The development of the new EU Global Health Strategy (European Commission, 2022b) was announced at the G7 Development and Health Ministerial Meeting in May 2022 and is expected to steer the EU’s priorities until 2030 (European Commission, 2022a). One of the main goals of the Strategy is to improve the ability of health systems to respond to and prevent global health threats in coming years (European Commission, 2022b).

The G7 has underlined the importance of health security several times, for example during the UK Presidency at the G7 meeting in 2021 where the Carbis Bay report was produced. The report speaks to advancing UHC and global health through strengthening health systems, preparedness and resilience, priorities which are clearly reflected in the new Global Health Strategy. In May 2022, G7 leaders met and agreed on a joint Pact for Pandemic Preparedness to strengthen pandemic readiness, including building a global network for stronger surveillance systems and strengthening pandemic response readiness (G7 Germany, 2022).

The EU plays a longstanding role in HSS (European Commission, undated, q). Six pillars of aid were designed to help strengthen health systems:

• Health service delivery – We help our partner countries provide quality health services in fit-for-purpose facilities.
• Health workforce – We support them in training and hiring sufficient and qualified health workers.
• Health information systems – We help them develop sound health information and spread it efficiently among their population.
• Access to essential medicines – We help them ensure that everyone has access to essential medicines at an affordable price.
• Health systems financing – We support them in defining adequate health financing policies.
• Leadership and governance – We make sure their health system is managed in a way that meets the needs of people, based on political commitment and accountable leadership.

The EU has a number of priorities in multilateral forums that touch on health. Although not directly related to health, the EU’s priorities with regards to global economic policy governance include enhancing public and private investment, ensuring tax fairness and transparency, and enabling free and fair trade. In terms of the G7’s foreign and security policy, the EU has made it a priority to support Ukraine after the Russian Federation’s invasion in February 2022. Support is primarily provided in financial form, but the EU and the G7 have also adopted sanctions and restrictive actions against the Russian Federation. Within the area of foreign policy and security, the EU is also leading an international response to the Syrian and broader Mediterranean refugee issues, which heavily affect it and do not offer easy and humane solutions (European Commission, 2015b). It has also set out a European Agenda on Security (European Commission, 2020b). The aim of the agenda is to tackle security threats as well as setting up a common multilateral effort directed at fighting terrorism, organized crime and cybercrime. The role of the EU in climate change culminates in the European Energy Union Strategy, wherein the EU has committed to the world’s most ambitious and legally binding reduction targets worldwide (European Commission, undated, r). The final G7 agenda area is that of development. Here, the EU has proven to be a leading financial contributor to achieving the SDGs. Food security is one of the biggest priorities for the EU in terms of development. As highlighted in the section on ‘Official development assistance and humanitarian aid’, support for food and nutrition security is primarily financed through the geographical and thematic programmes of Global Europe.

Through its membership of the G20, the EU can influence other countries to commit to and follow its priorities

The EU is a full member of the G20, and although the G20 is less Eurocentric than the G7, the EU still has a considerable amount of influence. The G20 is seen as an important venue for the EU in its attempts to influence other countries to commit to and follow its priorities. These priorities include: responding effectively to the consequences of the coronavirus crisis; mobilizing resources to ensure universal and equitable access to COVID-19 vaccines; and, in parallel, supporting global recovery (European Commission, undated, s). Furthermore, it is believed that high compliance to G20 commitments would strengthen the EU’s voice in general as well as its influence over the G20 (European Economic and Social Committee, 2011). Concrete issues influenced by the EU and its Member States include inter alia, a stronger oversight of credit rating agencies, more rigid regulation of bankers’ bonuses, and an increase in resources for the International Monetary Fund (IMF) (Hodson, 2011; for more detail, see Amtenbrink et al., 2015).

The G20 Pandemic fund builds on the 20221 Financial Intermediary Fund for Pandemic Prevention, Preparedness and Response, which was established by the World Bank with the support of the G20 in response to COVID-19 (World Bank, 2022a). The Pandemic Fund finances critical investments that strengthen pandemic prevention, preparedness and response capacities at national, regional and global levels. The predominant aim of the Pandemic Fund is to assist LMICs in strengthening PPR and to help them fill existing capacity gaps in core domains of the International Health Regulations (IHR). When the creation of the FIF was agreed upon in the summer of 2022, the EU facilitated a donor meeting to help prepare for its establishment. In addition, the European Commission, as well as several other organizations, committed funds in support of the FIF. The EIB is one of many pre-accredited entities that will serve as an implementing partner for PPR. In November 2022 the Bali G20 summit launched it as the Pandemic Fund (World Bank, 2022b).

Box 15

Declaring commitment to ending COVID-19 and improving preparedness for future pandemics at the Global Health Summit 2021.

The EU works closely with the UN in the areas of development, human rights and humanitarian assistance

The EU and its Member States are, collectively, the largest financial contributor to the UN system (EEAS, undated). This applies not only to the standard budget, but also to the funding of ODA (as highlighted in previous sections) and peace-keeping missions. From a political standpoint, the EU works closely with the UN in the areas of humanitarian aid, development, human rights and humanitarian assistance. Geneva and New York are the main communication hubs for the coordination between both partners.

In the area of human rights, the EU proposes resolutions and makes declarations on the protection and promotion of human rights and fundamental freedoms. In addition, the EU was pivotal in establishing and developing the system of UN Special Rapporteurs on human rights issues. Relative to sustainable development and the environment, the EU ensures that important UN conventions enter into force. With regards to humanitarian aid, DG ECHO has been funding and coordinating humanitarian missions, providing relief supplies and services in the form of food, medicines, fuel and medical and logistical experts since its founding in 1992 (more information on DG ECHO’s work is provided in the section on ‘Official development assistance and humanitarian aid’).

Figure 2

2013–2020 EU commitments to UN bodies. Source: EEAS, undated.

While each of the EU countries is an independent member of the UN, they all support the UN’s foreign and security policy. The EU’s interests are coordinated with the main committees, subsidiary bodies and other bodies of the UN (UNRIC, 2021).

Within the UN system, collaborations with the WFP, UNDP and WHO are particularly relevant for the EU’s Global Health Strategy

Perhaps the most relevant UN relationship is between the EU and the WHO. The two organizations have a longstanding strategic partnership in which they support countries in achieving the SDG 3 on good health and well-being including all other health-related targets within the SDG framework. The partnership works through regular high-level strategic dialogues, including the EU’s participation in the World Health Assembly, which lead to shared commitments towards strengthening health care systems, working towards the achievement of UHC, and improving capacities and responses to health emergencies across countries (WHO, 2022). During the COVID-19 pandemic, the WHO and EU created an even stronger working relationship under the Team Europe partnership, where their goal was to work together to end the pandemic and support the creation of more resilient health systems. Specifically, the EU engages in and with WHO resolutions on COVID-19 and is working to strengthen the WHO as well as the European Council’s proposal to form a global pandemic treaty (Bergner, 2023). Such a treaty would follow two earlier international legal instruments, which marked the EU’s support for the WHO. The first was the IHR created in 2005 in order to provide an overarching legal framework that defines countries’ rights and obligations in handling public health events and emergencies that have the potential to cross borders. The second is the Framework Convention on Tobacco Control (FCTC). This was the first international treaty negotiated under the auspices of the WHO and was developed in response to the globalization of the tobacco epidemic. It is an evidence-based treaty that came into force in 2005 and contains guidelines and requirements for the implementation of the most cost-effective tobacco control measures available. The EU and all of its Member States ratified the treaty reaffirming the right of all people to the highest standards of health.

The new Global Health Strategy and the 2024 Council conclusions re-emphasize the EU’s support for a strong WHO at the core of the global health governance system. Securing the financial sustainability of the WHO is viewed as a key element of this. The Commission also seeks, as part of the Strategy, to have the EU become a formal observer of the WHO with full participation rights (European Commission, 2022b).

There are many ongoing collaborations including in the area of universal health coverage and avenues for more concerted actions around One Health.

One concrete example of an ongoing collaboration between the EU and the WHO is the so-called ‘Health Clusters’. The WHO and DG ECHO joined forces to relieve suffering and save lives in humanitarian emergencies.

There are currently 31 Health Clusters/Sectors, wherein two are regional coordination mechanisms (Health Cluster, undated). The coordinators are responsible for facilitating and coordinating the health partners in relevant countries with the goal of delivering quality programmes and services to affected populations.

Box 16

The Quadripartite Memorandum of Understanding (MoU): Avenues for collaboration on One Health.

A further example is the Universal Health Coverage Partnership to expand UHC. Launched in 2011, the WHO and the EU forged a multilateral commitment between global and country action to make health accessible and available for all. The EU is the largest contributor in terms of funding ($168 million) and collaboration (WHO, 2022). The EU is committed to helping the WHO achieve its goal of 1 billion more people benefiting from UHC by 2023 (European Commission, undated, t). Through this partnership, the EU supports 115 countries in Asia, Africa, Latin America and Europe, helping to ensure access to preventive, curative and rehabilitative health services of quality without financial hardship. Most countries within the WHO European Region offer UHC; however, many people within the region still have to pay out of pocket for needed health services and medication. In an effort to decrease the financial barriers to accessing health care services, the WHO Regional Office for Europe offers tailored policy advice and policy dialogues on key issues in health financing policy.

The EU is also a significant financial supporter of the WHO’s Global Strategy and Plan of Action on Public Health, Innovation and Intellectual Property, which “aims to promote new thinking on innovation and access to medicines, as well as… provide a medium-term framework for securing an enhanced and sustainable basis for needs-driven essential health research and development relevant to diseases which disproportionately affect developing countries, proposing clear objectives and priorities for R&D, and estimating funding needs in this area.” The Strategy and Plan of Action are very clearly designed to work with the TRIPS agreement and waiver provision, noting that the “Doha Ministerial Declaration on the TRIPS Agreement and Public Health confirms that the agreement does not and should not prevent members from taking measures to protect public health” (WHO, 2008).

Another specific example can be found in the partnership for health in Europe between the WHO Regional Office for Europe, the European Commission and the European Union (European Commission, 2020c). The ambition of this partnership is to achieve the highest level of health and health protection, in line with the SDGs, most specifically SDG 3. There are five key priorities:

1. Strengthening health security against health emergencies and other threats.
2. Strengthening effective, accessible, resilient and innovative health systems.
3. Reducing the impact of non-communicable diseases, with a focus on cancer.
4. Promoting sustainable food systems and health.
5. Promoting health cooperation with non-EU-countries.

The partnership aims to exchange information and best practices, consult with one another, coordinate activities, and consider joint actions and initiatives. A more concrete cooperation plan between the two partners is under development (WHO, 2022).

Over the past few years, COVID-19 has been one of the top priorities on the EU’s and WHO’s agendas

In recent years, the top priorities on the EU and WHO agendas have been the COVID-19 pandemic response, health systems strengthening and UHC, access to medicines, health emergencies and humanitarian aid, global health security, One Health and health determinants. All link to the recognition that health knows no borders and that health security depends not on one country but all, as further cemented in the Global Health Strategy.

As previously mentioned, the COVID-19 pandemic response was instituted as a collective project known as Team Europe, through which EU institutions collected 26 billion euros to aid countries and international partners in their response to COVID-19. Team Europe played a substantial role in the launching of the ACT-A wherein the COVAX partnership rests (see Box 14). This global cooperation platform unites governments, health organizations, NGOs and civil society to ensure access to COVID-19 tools, such as vaccines, tests and efforts to improve health systems (WHO, undated, b).

Improving access to medicines falls under the Team Europe competencies through which the EU will continue to support the cause in advancing regulatory convergence, harmonization and use of reliance mechanisms, facilitating technology transfer and capacity building for local production, and improving governance, demand consolidation and strategic purchasing. These contributions are designed to help African partners create a sustainable foundation that ensures UHC as well as creating job opportunities for young African generations.

Health emergencies and humanitarian aid are covered through DG ECHO where the EU supports the outbreak and crisis response operations of the WHO health emergencies programme worldwide. The partnership between the WHO and DG ECHO provides vital humanitarian relief and assistance to the most vulnerable and fragile communities that are particularly impacted by health emergencies (see the section on ‘Official development assistance and humanitarian aid’ for further information).

The WHO and its Member States initiate resolutions at the World Health Assembly to strengthen WHO preparedness and response to health emergencies. These resolutions assist in gathering lessons from the pandemic in order to improve the systems and tools used for prevention, preparedness and response (WHO, 2021). The One Health approach is a cooperation between the EU and the WHO at the global, regional and national levels to address AMR (WHO, undated, d). The stated goal and focus of the cooperation is to assist countries in strengthening their capacities so that they may better prevent and control current and future global health challenges. Deepening the collaboration with the Quadripartite is one of the key actions highlighted in the new Strategy (see Box 16 for more information on the Quadripartite).

Humanitarian action is a key strand of the EU and UN’s joint work

The World Food Programme (WFP) is the largest humanitarian organization working towards zero hunger and has been collaborating with the EU since 1996. Specifically through the financial support of the European Member States, the European Commission, DG ECHO (European Commission’s Civil Protection and Humanitarian Aid Operations), DG INTPA (European Commission’s Directorate-General for International Partnerships) and DG NEAR (European Commission’s Directorate-General for Neighbourhood and Enlargement Negotiations), several humanitarian logistics and supply-chain actions were able to be executed thereby helping to repair the global disruptions to the transport systems during the pandemic (WFP, 2020a).

Box 17

Country examples of the EU’s collaboration with the World Food Programme.

The United Nations Development Programme (UNDP) and the EU have been working together since 2004 and are currently cooperating to support countries in their aim to achieve the Agenda 2030 for Sustainable Development. The main goal of this multilateral cooperation is to work with partners in other countries in order to increase the resilience of people and their communities in order to restore infrastructure, provide basic services and create jobs. Examples of initiatives can be found in Yemen, where thousands of people have been given access to food, jobs and electricity, and in the Caribbean, where improved procedures have enabled better disaster preparedness (UNDP, undated).

The EU also pursues priorities in health by cooperating with multiple stakeholders across the private sector and civil society, including private philanthropic organizations, such as the Gates Foundation

Beyond its collaboration with multilateral organizations and governments, the EU also pursues priorities in health by cooperating with actors from the private sector and civil society, including private philanthropic organizations. One of these important partnerships is with the Gates Foundation. The Bill & Melinda Gates Foundation is a non-profit organization founded by Bill and Melinda Gates at the turn of the 21st century. The EU and the Gates Foundation have collaborated with the stated aim of reducing poverty and improving health throughout the developing world (Bill & Melinda Gates Foundation, undated). One collaborative project was, for example, supporting health services in Africa. The Gates Foundation contributed 54 million euros to the External Investment Plan helping the EU efforts to strengthen diagnostic health services in Sub-Saharan Africa (European Commission, 2018). Another example of an important collaboration is the African drugs regulator, the African Medicines Agency, for which the EU, the Gates Foundation and other countries have provided financial support. Both institutions will invest 100 million euros over five years (until 2027) to assist Africa’s drug and vaccine production (Reuters, 2022). As highlighted in an earlier section of the brief, additional funding to strengthen the AMA is being disbursed within the scope of the Team Europe initiative MAV+ (see Box 8 for further details).

Box 18

Transversal topics.

Horizon Europe and NextGenEU are powerful funding tools that enable European researchers to promote science in diplomacy

A major force for Europe is its robust funding schemes. Multiple iterations within its powerful Horizon Europe and other NextGenEU funding tools provide opportunities for European researchers and promote the other strands of science in diplomacy. The 2021–2027 MFF focuses on major challenges. Beyond social health factors, global cooperation to further develop technologies persists. These technologies include surveillance mechanisms, medicines and vaccines, and digital technologies. Further development can occur in digital spaces as time progresses. Horizon Europe funds multiple successful programmes that spread health information and support virtual exchanges of information. Some examples are provided below.

European and Developing Countries Clinical Trials Partnership

Promoting cross-border partnerships that address ongoing issues as well as form diplomatic ties is important. Within Horizon Europe exists the European and Developing Countries Clinical Trials Partnership, which aims to foster partnership between researchers in Sub-Saharan Africa and Europe. EDCTP began in 2003, initially to investigate vaccine solutions for communicable diseases including malaria and HIV. The partnership formed to bridge Sub-Saharan African and European scientists (Olesen, 2018; European Commission, undated, v). Thus, health technologies that prevent the spread of infectious and emerging diseases are at the forefront of EDCTP’s focus (EDCTP, 2022). Since its inception, EDCTP has expanded to support development of research and development beyond communicable diseases by supporting partnerships between private and public sectors (Tanner, 2017).

Table 3

Examples of initiatives supported by Horizon Europe 2021–2027.

Previously, the EU Commission has had two periods of this initiative, with it renewed for a third time in November 2021. The latest iteration of EDCTP3 again focuses on forming partnerships between European and African researchers (see the section on ‘The EU and the Gates Foundation’), with 1.8 billion euros provided to pursue the goal of preventing the spread of diseases as well as re-emerging infectious diseases. The first call for proposals was released in 2022. The ultimate goal is to support over 100 research institutes in 30 countries to develop at least two health technologies fighting infectious or emerging diseases. As Europe moves into the third EDCTP initiative, the focus will begin to shift on providing greater capacity for those outside of Europe. EDCTP3 will promote Africa-driven research (EDCTP, 2021, 2022), further emphasizing Europe’s ability to promote global health while also acknowledging the voice of its partners.

As the flagship global health initiative, EDCTP has developed Europe’s work in global health. Beyond providing funding for clinical trials, EDCTP’s progressive framework focuses on capacity building for researchers of all types, and provides programmes centred on ethics and training in an effort to expand the research network with its partner countries. The ECDTP’s 2021 annual report highlighted that the programme had provided training for over 150 epidemiologists and biostatisticians (EDCTP, 2021, 2022).

The strengths of EDCTP lie in the partnerships made between Europe, Africa and interlocutors such as GAVI and Médecins Sans Frontières. The reach of the programme continues to expand, with the latest iteration adding three Sub-Saharan countries to the outreach. Partner countries continue to see the use of investing, as the budget has continued to increase with additional renewals (EDCTP, 2022).

New EU programmes support the virtual exchange of information creating access for global contributors

One of the largest trade partners is also a major information and technical partner: Africa. The popular EU–AU Partnership provides many programmes that promote scientific diplomacy through science for diplomacy and diplomacy in science.

New programmes support the virtual exchange of information. There are multiple formats that this could take. A recent initiative that displays the European Commission’s potential is Knowledge4Policy (see Table 2) (European Commission, undated, w). This is an effort produced to create a knowledge base through which researchers may submit and share data and findings with the online community. Being in the virtual format allows global contributors access. Providing a knowledge base allows for science in diplomacy, giving a centralized source of information where policy makers can look for information. Since launching in April 2022, Knowledge4Policy has already attracted many health researchers. As of September 2022, there are over 1300 publications that appear related to health. Forty-six datasets have been added to the database. Within the overall Knowledge4Policy, there are initiatives to provide health researchers with health data; for instance, the Knowledge Centre for Bioeconomy exists within the framework to promote better information for bioeconomy-related policy-making (European Commission, 2022q). The Knowledge Centre for Global Food and Nutrition Security provides a knowledge service that displays Europe’s discussion of equal access to food and nutrition, with the database providing further backup for inter-policy dialogue (European Commission, undated, x).

An important form of technical support comprises training of the global health workforce

The EU has a long history of supporting technical assistance and training, and instruments that allow sharing of tasks across borders are beginning to see more funding. Examples of partnerships involving support from European diplomats occur to promote technical assistance. Vocational training has been a refocus of EU partnerships, with programming to train additionally needed staff in partner countries and organizations, as seen in the Opportunity Driven Vocation Training Team Europe initiative. This partnership occurs in conjunction with the Manufacturing Pharmaceuticals with Africa; a similar manufacturing agreement with the Latin and Caribbean areas is currently in the works and will function as an initiative to promote bilateral agreements and address the ongoing concerns on AMR (Principle 17) (European Commission, 2022b).

Box 19

Transversal topics.