The Enlargement Process and Challenges for the Health Sector
Editor European Affairs
This article reviews health statistics of ten new Member States and the challenges ahead for these and the EU to achieve comparable standards in health care across Europe
The accession to the European Union of ten new Member States (Estonia, Latvia, Lithuania, Malta, Poland, Slovakia, Slovenia, the Czech Republic, Hungary and Cyprus) on 1st May increased the EU’s population by a fifth and created a further 75 million European citizens overnight.Two further candidate countries, Bulgaria and Romania, hope to join the Union by 2007, while accession negotiations with Turkey, which has also applied for EU membership, have yet to receive approval.
In terms of its scope and diversity, this round of enlargement has been unprecedented. In the area of health, for example, data on this highly disparate “group of ten” show stark differences in the health status of their respective populations and the performance of their health systems. Most lag well behind the established Member States – the EU15 – in terms of core health indicators and expenditure. In the majority of the new Member States, for example, life expectancy at birth remains well below the EU average, despite notable improvements in recent years.
The ten countries were obliged to adopt the acquis communautaire of the European Union by 1st May 2004 or, in certain circumstances, by the end of an agreed transition period. The acquis is the body of legal and administrative provisions arising from the Treaties of Rome (25th March 1957), Maastricht (7th February 1992) and Amsterdam (16th and 17th June 1997).
Each of the new Member States agreed to transpose into national law all EU legislation in the field of public health by 1st May 2004. This includes, for example, legislative instruments for the surveillance and control of infectious disease and the reduction of tobacco consumption.
EU legislation in the field of surveillance and control of infectious diseases is underpinned by the so-called network decision (2119/98/EC), which establishes a Community-wide network to promote cooperation among the Member States and co-ordinate appropriate activities, with the aim of improving protection against the spread of infectious disease in Europe. Before joining the Union, the acceding countries were required to take all necessary steps to guarantee their full participation in the network’s activities. They were also obliged to adopt a plethora of health-related laws, with transitional arrangements available in some cases, on issues such as mobility for members of the health professions, patient mobility, the free movement of health-related goods and services, environmental protection and food safety.
Health in the New Member States
Comparisons between health status and standards of care in the EU15 and the group of ten show marked differences. Over the years the health systems of the new Member States have developed their own traits and traditions and consequently each faces a unique set of challenges. Nevertheless, it is possible to make a number of generalizations about the group. For instance, the gap between spending on health care in the new and established Member States is significant. The new Member States spend on average just 5% of Gross Domestic Product on health, although the figure varies significantly within the group. In contrast, health expenditure among the EU15 averages more than 8% of GDP. Such low levels of resources for health care clearly impact on the provision of services, access to services, their quality and factors such as wages and salaries for members of the health professions.
Fighting disease is one area in which the new Member States and their 15 partners face very different problems. For decades, the problem of tuberculosis, for instance, appeared to be largely under control. However, according to a report on the efforts taken by 77 countries and regions of the world to combat tuberculosis, this benign picture could rapidly change. The study, published by the World Health Organization in March , points out that enlargement has brought several tuberculosis “hot spots” into the EU. These are regions in which the epidemic is rapidly developing. One of the worst affected regions is the Baltic States. In Estonia, for example, nearly one in eight patients do not respond properly to antituberculosis drug treatments. WHO has also reported a significant increase in antituberculosis drug resistance in Poland, while several experts have estimated that at least 35,000 people in Eastern Europe are infected with multi-resistant strains of the disease.
Major challenges lie ahead for most of the new Member States. In the field of health, the list is long and includes insufficient resources, dissatisfaction among medical professionals, increasing levels of alcohol and drug abuse and AIDS, to name but a few.
The European Union still has a long way to go before medical services of a comparable quality are available to all its citizens, irrespective of their nationality and location.
Member States must ensure that they pay close attention to the
EU’s developing role in health policy and translate changes at EU level into
action on the ground. The recent establishment of a new EU-wide health agency
and the imminent creation of another are two cases in point. The new Member
States are required to develop effective administrative structures at national level
to work smoothly with new agencies such as the European Food Safety Authority and
the European Centre for Disease Prevention and Control. The enlargement process
is the outcome of years of partnership between the EU15 and the group of ten
new Member States. Working together to find ways to iron out continuing
difficulties in the health sector will present a major challenge for this
partnership in future. To achieve this, all 25 Member States will have to
engage with and learn from their partners, not only for the benefit of the new
Member States, but also because it is in the interests of long established EU
members. Achieving comparable standards of health care across the Community is
just as important as political and economic stability.
1. World Health Organization (WHO). Anti-Tuberculosis Drug Resistance in the World – Third Global Report, 16th March 2004, available