Some in the V4 are reluctant to give up healthcare competencies to the EU

2021-03-05

The European Union, as the rest of the world, is facing an unprecedented healthcare challenge. The EU has been widely criticized for its slow initial reaction to the developing pandemic and, then, the slow vaccine roll-out in the bloc, seeing the Union lag behind the US, the UK or Israel in the immunization of the population.

By Patrik Szicherle (Political Capital), Zuzana Gabrižová (EURACTIV.sk), Ondřej Plevák (EURACTIV.cz), Michał Strzałkowski (EURACTIV.pl)

European pandemic management

EU institutions reacted late to COVID-19 and did not convey a sense of urgency until March, while member states failed to show solidarity with Italy, deciding instead to stockpile crucial equipment for themselves. Things would improve eventually: EU members took over Italian COVID patients, offered the help of their medical professionals to Italy, and delivered medical equipment to the country.

The long-term, wider Slovak debate on the EU´s management of the pandemic as such has mirrored the European one. However, some politicians acknowledged that this was also the fault of member states. “In the spring, first wave has brought problematic situation when countries in the state of shock blocked deliveries of respirators, mask and other medical material,” MEP Monika Beňová (Smer-SD, S&D), member of the ENVI Committee of the European Parliament, thinks.

István Ujhelyi, an MEP representing the Hungarian Socialist Party (S&D), highlighted that the EU faced an unprecedented challenge without any protocols, practices in place to handle it, so the key now is to be better prepared for future crises – if they ever come. 

Moving medicine production to Europe

During the first wave, one of the key demands on the European level was moving medicines production back to European territory to avoid the product shortages experienced during the first wave. Gabriella Lantos, the healthcare policy expert of the Hungarian center-right New World – People’s Party and the former operative director of the Róbert Károly Private Hospital in Budapest, says that it would be important for Europe to be self-sufficient in medicine production, but this could “only take place gradually, the current supply chains can only be eliminated after the new infrastructure is in place.”  

Addressing the problem of medical equipment, Slovak MEP Vladimír Bilčík (SPOLU-OD, EPP) says that the “production of strategically important medical material in Europe is necessary and must be a priority.”

At the outset of the pandemic, Slovakia discovered that state reserves were pretty much empty of any useful material (the former head of the State Reserves is now in custody for corruption) and opted for emergency, yet costly deliveries from China before the situation stabilized.

Production capacities in Europe have been naturally focused on the production with higher added values, while less sophisticated products such as protection wear, respirators or mask were produced outside of the EU, says Vladimír Bilčík, adding that European production capacities have clearly not been able to respond to sudden demand.

“We should monitor the readiness of our industry to react to the current demand in the pandemic and whether it is capable to change the production to protective gear, for instance, should the necessity arise. I am convinced we should keep an eye on this and finance the preparedness for the change of production,” Bilčík argues. “We should never again find ourselves in a situation where people die due to a shortage of respirators worth several tens of cents and volunteers will step in the place of the state.” He praised that the creation of European strategic stocks was one of the first measures taken by the European Commission.

“We should intensively invest in vaccine production, similarly to investment in its research and development. The production of so badly needed vaccines can be now stepped up precisely because of the additional investments into production within the EU,” Bilčík adds.

However, when it comes to proposals to return the production capacities of medical products back to Europe, there are different ideas as well. Tomáš Doležal, a Czech economist focused on pharmaceutical sector, pointed out that ensuring EU self-sufficiency in the supply of these products would be associated with increased costs for research, development and in-house production. “A detailed economic impact study is needed. Europe has benefited and is benefiting from high investment in the US and cheap labor in India and China. I would rather be in favor of strengthening investment in research and development through a fair price for innovation and efficient and safe products,” Doležal said.

Czech Communist MEP Kateřina Konečná (GUE/NGL), however, says that the return of production of key medical products to Europe is essential. What, in her opinion, deforms the market and discourages companies from producing here are, for example, obsolete patent protection rules or strict restrictions in the area of generic drug development and distribution.

The Czech Association of Pharmaceutical Companies (ČAFF) believes the way to increase the level of EU drug production self-sufficiency is to change the regulatory framework to better stimulate investments in research and production capacities. The current EU pricing policy, where the lowest price is always preferred, is one of the main reasons why a large number of suppliers are located outside the EU, ČAFF claims.

Vaccine purchases: most of the V4 is unhappy

The European Union also put in place an ambitious joint vaccine purchasing program. The European Commission, with full backing from the 27 member states, has thus managed to secure more than enough jabs to immunize the EU’s population against the coronavirus. However, the effort has been mired by the slower than expected delivery of the vaccines by manufacturers. The EU executive body is being criticized for concluding the vaccine contracts too late, while the European Center for Disease Control (ECDC) has been accused of approving jabs too slowly.

Czech Prime Minister Andrej Babiš, whose government is currently failing to get the COVID-19 epidemic under control, has repeatedly criticized various European Commission decisions regarding the ongoing crisis. The Commission was in his eyes “too slow” in procuring vaccines, as he said in January. However, the Ministry of Health has noted the Czech Republic would not be able to secure a sufficient number of doses without the EU’s joint approach.

Regarding the import of non-EMA approved vaccines, PM Babiš visited countries which have already given a green light to Russian or Chinese vaccines to “learn about their experience”. Despite top elected officials later agreeing that COVID vaccines that will be used in the Czech Republic must pass the current EMA approval process, Babiš together with the pro-Russian and pro-Chinese President Miloš Zeman are trying to get Sputnik V into the country. Health Minister Jan Blatný is strongly against using non-EMA vaccines.

The Hungarian government’s official coronavirus site, for instance, regularly notes in its COVID-related news that “Since only a few vaccines are arriving slowly from Brussels’ acquisitions, Hungary is doing everything to secure enough jabs to start mass vaccinations.” Lantos says that “the real limit on vaccination in Europe is production capacities,” which is why self-sufficiency in medicine production would be crucial.

Polish authorities are also critical of the European Union’s performance in the face of the COVID-19 pandemic, primarily the Commission’s joint vaccine acquisition program. "Unfortunately, it can be said that the EU purchasing policy will be partly responsible for the fact that we have the third wave of the pandemic in Europe," said Minister of Health Adam Niedzielski. The minister added that "in January we rushed with vaccinations, but then we had to slow down."

The EU institutions are in a tough position, but their role in approving the vaccines (EMA) and the common procurements is positive, Tomáš Doležal told EURACTIV.cz. In his opinion, small states like Czechia are in a much better negotiating position thanks to the EU.

Kateřina Konečná also thinks that despite the fact health policy is only complementary at the EU level, the Union is doing rather well during the current pandemic. She highlighted that vaccine development was possible thanks to the EU, which has invested hundreds of millions of euros in the early stages and also changed its regulatory framework so the doses could be used within months. However according to her there were also mistakes. “The failures certainly include the non-transparent negotiation of vaccine purchase agreements and their final wording,” Konečná added.

István Ujhelyi noted to Political Capital that Hungary benefited from the EU’s joint vaccine program because without it, stronger, more affluent member states would have had a much better chance of securing jabs.

Hungary’s former hospital operative director believes that if Hungary could reach herd immunity thanks to the 1-2 million doses of eastern vaccines, it would be a considerable success that could shake other states’ trust in the EU’s joint program, but “I believe it will not materialize in the end because trust in vaccines is low already due to the government’s secretive handling of the pandemic.”  

Dr. Melchior Szczepanik from the Polish Institute of International Affairs believes that the decision of the EU Member States to jointly purchase vaccines was right, because they did not compete for the supply of preparations.

“The idea was to prevent some Member States from having too many of these vaccines, and some not having them at all. This would lead to political disputes that would hinder the functioning of the single market. However, if we can point out something to the European Commission, this is mostly its overly optimistic approach that pharmaceutical companies will fully comply with the contracts concluded,” the expert said.

In turn, Dr. Małgorzata Gałązka-Sobotka from the Institute of Healthcare Management
at the Lazarski University in Warsaw
 estimated that it was impossible to avoid normal market rules for the purchase of coronavirus vaccines, based on supply and demand. "But if you look at Ukraine or many other countries in the world, they either do not have access to vaccines
at all or have received very little number of doses" - emphasized the expert.

No agreement on the Health Union

As is the case generally after deep crises, work began on reforms potentially addressing shortcomings. The European Commission laid out its healthcare-related plans in November 2020. Health Commissioner Stella Kyriakides envisions a European Union able to declare its own health emergencies, create EU-wide pandemic preparedness plans, develop a new agency for health emergencies, and require more data from member states. Crucially, the reform would also allow the ECDC to issue policy recommendations to member states. Speaking for the Commission, Czech Commissioner for Values and Transparency Věra Jourová said in November that the EU needs to improve communication not only on medicines and medical equipment, but also on various diseases and cross-border health threats.

In Slovakia, there has hardly been a public discussion on the Health Union proposals of the Commission. The Slovak Ministry of Health told EURACTIV Slovakia only that they “welcome and support the establishment of the European Health Union” to “strengthen resilience of the EU in case of cross-border health crises.” They noted that the “The lessons learned from this pandemic show that joining forces of helps to overcome the weaknesses of individual the member states’ health systems.”

Monika Beňová appreciates that solidarity, common approach and coordination has prevailed in the end. “This cannot be taken for granted.” She fully supports the common procurement of vaccines, and the agreement to move forward with the European Health Union, including strengthening the role of several EU agencies, further building up European strategic reserves or EU4Health program.

Her colleague, MEP Martin Hojsík (Renew, PS), another member of ENVI, says people rightly expect the EU to deliver in these kinds of crises. “The lessons learned for me is that we need processes to enable us to proceed in a coordinated manner and this should also include new competences.” Despite some setbacks, he also considers vaccine procurement a success. “From the global perspective, Slovakia has emerged in the elite club of countries which have access to safe and certified vaccines,” Hojsík adds.

The Hungarian socialist MEP said that the European Commission’s plans are largely built on the healthcare strategy approved by the European parliament, including a system of criteria that ensures that all European citizens have access to high-quality healthcare.

However, EU ambition will likely stop short of demanding member states to transfer more healthcare competencies to the bloc, as it could make strong resistance. The Czech government has so far not responded to the EU Health Union proposal or even disseminated its views to the media. In a more general sense, the Czech Republic has not shown any intention to push for the EU to have more powers in the future.

Tomáš Doležal would agree with strengthening the EU powers in health agenda. “During the free movement of persons, infectious diseases know no boundaries. One of the (strengthened) areas could be the coordination of testing, tracing, rules of movement, as well as the coordination of health capacities within cross-border care. And I would certainly welcome the strengthening of Europe's role in the joint clinical trials of new technologies through HTA (Health Technology Assessment),” Doležal told EURACTIV.cz.

Kateřina Konečná, who was responsible for the ECDC in the European Parliament in the past, thinks the presented changes regarding the agency are “only cosmetic”. The MEP believes that in the case of cross-border threats the EU would benefit from moving from agency recommendations to mandatory directives for the member states.

Edina Tóth, an MEP from the Hungarian ruling Fidesz party, said during a plenary debate on the EU’s post-COVID healthcare strategy that “I believe we do not need the European healthcare minimum proposed by the left but the highest level of health protection for EU citizens,” suggesting that the bloc should “cooperate with member states, support them and harmonize their measures.” However, the MEP did welcome the financial resources set aside for the EU4Health program and the Commission’s earlier proposals. István Ujhelyi, in contrast, supports “rethinking certain national competence” because COVID-19 proved that some challenges can only be mitigated via cooperation. Ujhelyi highlighted that “we need to find the golden middle road ensuring that member states’ competencies are not harmed but the lives and health are secured equally.”   

According to Gabriella Lantos, the European Union needs to have joint healthcare minimum standards, especially in emergencies, “so some of member states’ competencies must be lifted to the EU level.” She highlighted that a single market requires unified rules on movement and economic restrictions.

In Poland, due to the relatively mild course of the COVID-19 pandemic compared to other parts of Europe, there has been no serious discussion on increasing the EU's powers in matters relating to health protection. However, it seems unlikely that the current conservative Polish government will advocate such changes, as it presents a different approach to issues such as abortion, euthanasia, infertility treatment and contraception than most Member States.

Slovakia’s facing the worst of the pandemic

Despite the increasing speed of vaccination, Slovakia has found itself facing the worst of the pandemic since its outbreak in February, albeit severe lockdown restrictions have been in place since early January. The country was the worst in the world in the number of deaths and hospitalizations per 100,000 late that month. The exact reasons for this are unclear, as reliable and comprehensive data are simply absent: the ongoing nation-wide antigen testing results are getting mixed up with results from the official PCR testing.

So far, Slovakia got 400,000 of doses of vaccines. Until the end of March, another 850,000 is expected to arrive and at that point, not more than 15% of the adult population is expected to be vaccinated. There are also estimates – based on the EU vaccine distribution plans – that by the end of the summer, 70 % of the population could be covered. In Slovakia, the issue of the (un)willingness to get a vaccine is to be considered. According to the last opinion poll, 20 % of respondents say they will not get a shot, while 40 % of them are still hesitant.

Vaccination is voluntary in Slovakia. The Ministry of Health has launched an information campaign using influencers, celebrities and personalities who declare their readiness to get a shot once they themselves are eligible. Politicians, who already got their shot, such as President Zuzana Čaputová, also made a public occasion out of it.

The roll-out of the vaccination process in Slovakia was not without hiccups. While in some places in the country, slots for vaccinatiosn for target groups have been filled up, in other locations they struggled to find enough people to be vaccinated, which, most likely, resulted in some doses of the Pfizer/BioNTech vaccine going to waste. It is also unclear, even classified, according to state authorities, who is to be considered part of the “critical infrastructure”, one of the first groups to be vaccinated, which inevitably creates lack of transparency. The media got hold of the information that former prominent Slovak tennis player in her 30s and her husband got a shot despite not being eligible. Currently, after the medical staff, senior citizens and teachers are being gradually vaccinated, using mostly vaccines from AstraZeneca.

In the midst of heavy criticism of the government for the management of the pandemic, Prime Minister Igor Matovič has proposed Slovakia proceed with purchase of Russian Sputnik V. “My view is very close to Viktor Orbán´s on this. The protection of health and lives cannot be linked to geopolitics, the virus does not choose between the East and the West,” Matovič said during a V4 presser in Krakow. His plan, opposed by his own health minister, was to get at least national authorization for Sputnik V and offer the vaccine to those who are only willing to get the Russian vaccine. It is unclear how large of a group of people that would actually be. Besides, currently people are not in a position to choose a brand of vaccine they get, once its their turn to get one.

The first batch of 200,000 Russian Sputnik V vaccines arrived in Slovakia on March 1st, welcomed at Košice airport by Prime Minister Igor Matovič, who apparently did not consult with his coalition partners. While the country of five million is set to receive another 400,000 doses of the vaccine in March, it should have two million Sputnik V vaccines by June, according to the agreement signed with Moscow. With the Russian supplies, the vaccination rate could be accelerated by 40%, said the prime minister. The vaccines, which have not yet been approved by the European Medicines Agency (EMA), will only be administered to citizens after having passed the national control system. Recipients of the vaccine will need to sign an affidavit, confirming awareness that the vaccine is not registered in the EU. Two coalition partners of the four-party government have already expressed their disagreement with the idea of offering the unregistered jabs. “Vaccinating citizens with an unregistered vaccine, for which the European Medicines Agency has not properly verified its safety and efficacy, is neither correct nor safe,” said Deputy PM and leader of the junior coalition party For the People, Veronika Remišová. Only a week ago, Remišová said she had used her veto in government, refusing to allow further negotiations with Moscow

As for what is going to follow the pandemic in the healthcare sector, the Ministry of Health was thight-lipped: they only told EURACTIV Slovakia that “it has been doing its best since the beginning of the pandemic with the biggest challenge being the human factor.” They did add that during the pandemic, only procedures posing no risks to patients were delayed, “all the others are carried out and patients are given appropriate healthcare.”

In contrast, Slovakia seeks to act on European medical production capacities. In February, President Zuzana Čaputová got in touch with Thierry Breton, the European Commissioner for Internal Market in connection with the production of vaccines in Slovakia. She informed him that Slovakia is interested in working on the EU’s vaccine self-sufficiency. “The commissioner welcomes the information on production capacities available in Slovakia and stated that the European Commission can help with their utilization. Therefore, I asked the minister of health to provide the commissioner with more details. I was also interested in the possibility of the European Commission financially assisting with the necessary modernization of our laboratories. The commissioner confirmed the availability of such resources,” the president´s statement reads.   

Slovakia is also the home of the Chirana T. Injecta company, which for some time already supplies 20 countries European and non-European countries with large amounts of syringes and needles needed for current COVID-19 related vaccination campaigns, including those able to extract maximum doses from the vaccines. Chirana has only been approached by Slovak government at a very late stage, in January 2021, when the company´s capacities were already busy satisfying earlier demands. In the end, after the company made adjustments internally and thanks to delaying some supplies to countries which did not need them right away considering their pace of vaccination, the company will be able to supply to Slovakia´s healthcare system more than previously thought – 4 millions of syringes and 5 millions of needles.

Reforms are also on the table in Hungary

Hungary has also suffered the consequences of the coronavirus with around 147 deaths per 100,000 inhabitants. This is high compared to Austria (95 per 100,000), which the Hungarian cabinet deemed its “virus laboratory.” Hungary started its vaccination campaign on 26 December, and 4.9% of the population received the first dose of the jab by 23 February 2021, according to ECDC data. According to János Szlávik, the chief infectologist of the Dél-Pesti Central Hospital, everyone who wants to get vaccinated in Hungary could get one by the end of 2021, albeit the country did not have eastern vaccines available at the time. However, the low popularity of inoculation in Hungary is a concern that could derail plans.

The Hungarian government has taken steps to improve Hungary’s healthcare system, but the results have not been a clear success. The cabinet did implement a considerable base salary rise for doctors and introduced a new healthcare employment second jobs. Several doctors are thinking about refusing their new contracts. The cabinet is also planning to increase wages for general practitioners, but only those who form a “GP community” can receive the full, 100% rise.

Lantos believes that the key to the future of healthcare in Hungary is ensuring the availability of enough doctors and nurses, and the structure and extent of public healthcare service must be defined based on available personnel, which would have to satisfy the common EU minimal standard.

The Hungarian cabinet is also planning to use EU subsidies in the Recovery and Resilience Fund (RRF) to improve the infrastructural environment of and human resources in the healthcare system. Around one-sixth of the money allocated to Hungary in the RRF would be set aside to reach these goals. In addition, they would spend money on improving healthcare education as well.

Poland’s healthcare system tested

Over 2.7 million vaccinations have already been administered in Poland, with two doses received by almost 930 000 people, and the first dose received by 1.78 million. However, only about 15 000 vaccinations are currently performed daily. The government's representative for vaccination, Michał Dworczyk, assures that the possibilities are greater, but there are no vaccines.

"94 percent people from the so-called group zero, which includes doctors, nurses or other medical workers, have already been vaccinated. We will vaccinate the rest of this group in March, when a transport of 0.5 million doses of AstraZeneca will be delivered to us,” said Dworczyk.

In Poland, people over 70 are already being vaccinated, but so far only a part of this group
has received the jab. Vaccination dates are only scheduled up until the end of March.
For many people, there were not enough places, or they are to have the vaccine administered over 100 kilometers away from their place of residence. The first groups of teachers
have also got inoculated. The government says the immunization program will not accelerate until the EMA approves the Johson & Johnson vaccine.

Poland is also negotiating with several vaccine manufacturers to secure additional supplies
in the event of further delays in the implementation of contracts negotiated by the European Commission. However, there is no further information about the producers shared publicly, although it was stated that some of these vaccines “are still at the stage of registration.”

“These are difficult talks, because the producers who are just entering the market want
to trade with the European Commission, therefore they are afraid to negotiate with individual countries. We have many informal talks, which may lead us to conclude contracts
for additional batches of vaccines,” said Deputy Minister of Funds and Regional Policy Waldemar Buda. So far, no vaccines for coronavirus have been approved for use in Poland, apart from those already approved by the EMA.

In any case, Poland has had some luck during the COVID-19 pandemic, as its first wave was mild, especially compared to what took place in many other EU member states. The peak of the second wave at the turn of October and November only lasted about a month. The country has also avoided the wide spread of more infectious variants
of the coronavirus detected in the UK, South Africa and Brazil so far. Professor Krzysztof Pyrć from the Małopolska Center of Biotechnology at the Jagiellonian University in Kraków, whose team conducted research in this area, estimates that the so-called British variant of SARS-CoV-2 currently accounts for only about 5-10% of infections in Poland.

Thus, Poland’s public health service, despite having been underfunded and neglected by successful governments, has not collapsed under the pressure of the coronavirus so far. Nevertheless, the county has witnessed large queues of ambulances outside of hospitals during autumn 2020 and patients suspected of contacting COVID-19 being transported to multiple hospitals in search of a free place.

These issues led to the revival of discussions on healthcare financing, which was first triggered in 2017 by the strike of young doctors who demanded an increase in public spending on the sector 6.8% of the GDP. At the time, the government pledged to allocate up to 6% of the GDP to healthcare by 2025. This decision led to the end of the strike.

But in 2019, young doctors resumed their protest when it turned out that the government had decided to use the old Polish GDP indicators as a benchmark. However, they postponed another strike due to the outbreak of the COVID-19 pandemic. Now, they have announced
its resumption.

“The epidemic revealed shortcomings in the health care system, especially the staff shortage. Medical personnel who work in the public system are therefore very overloaded with work, equipment is either missing or broken and there is no one to fix it. It is hard to work
in such conditions,” says Piotr Pisula, chairman of the Alliance of Residents of the National Trade Union of Doctors.

Young doctors are therefore returning to their postulate to increase expenditure on healthcare to 6.8% of the GDP, and demand that it reaches 8% in the next few years. After the last meeting of the Social Dialogue Council, it turned out that the government is ready to make a small concession and agree to increase expenses on the sector to 6.5-7% of the GDP.

Czechia is lagging behind in inoculation

The current level of coordination seems insufficient when it comes to convincing the Czech Republic to follow the common recommendations. The prime example is the vaccination strategy. Czechia is lagging behind in the inoculation process, and despite asking other member states to temporarily share some of their vaccines (and succeeding), the country is not able to use up all the doses it already has. It is very hard to say when the herd immunity could be achieved and there are currently no plans of making vaccination compulsory for any societal group.

There have been a few attempts by the government to promote coronavirus vaccines in the media, a complex promotional campaign has not yet been introduced. The earliest estimates say that such a campaign would be launched the end of March. Nevertheless, it seems the problem is even bigger – according to analysts, Czechia lacks strategic communication abilities and therefore is quite vulnerable to disinformation about vaccines.

Despite standing strong at the beginning of the pandemic last spring, the Czech healthcare system was hit hard during the second and third wave, currently being under a huge pressure. Non-COVID-related treatments are being delayed and there seems to be no compensation plan in place. The important part of “getting back to normal” is making sure the national healthcare systems are resilient to similar crises in the future. MEP Konečná would welcome restoring intensive care capacities “devastated in the last decade” as well as more support for regional medical facilities. Representing the Communist party, she would like to see the end of privatisation and is promoting merging all public health insurance companies into one.

Tomáš Doležal thinks the Czech Republic needs to update its pandemic plan, “through which it will be possible to increase the capacity of testing, tracing and also intensive care beds in days or weeks.” As he mentioned, the pandemic has showed “desperately low” level of digitization of healthcare and a lack of objective data combined with a reluctance to share it even in anonymised and aggregated form.

EU funds will certainly help a lot in transforming the Czech healthcare system. Looking at the data from previous years, European money plays a more and more important role in this process. The government coalition still cannot agree on the exact distribution of money from cohesion funds into national programs. At this point in time, only the composition of additional resources from REACT-EU is known; healthcare will get over 70% of the allocation – around €740 million. The Recovery and Resilience Facility should also finance healthcare, but the current form of the Czech National recovery plan is not yet available.

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