In Networked EU Health Cooperation, Some Members Are More Equal than Others


By Reini Schrama, Dorte Sindbjerg Martinsen & Ellen Mastenbroek

COVID-19 put health policy in the European Union (EU) high up on the political agenda. Since the pandemic hit Europe, heads of states, health ministers and experts have increased their collaborative efforts to mitigate its effects. The president of the European Commission, Ursula von der Leyen announced closer collaboration among EU countries to “work together to detect, prepare and respond collectively” and proposed a stronger European Health Union. To do so, the mandate of both the European Medicine Agency (EMA) and the European Centre for Disease prevention and Control (ECDC) have been strengthened and a new Health Emergency Preparedness and Response Authority (HERA) has been established. These recent developments demonstrate how rapidly EU health cooperation surfaces at the face of a cross-border health crisis.


Expert networks in health cooperation

Under the surface, however, expert-driven health cooperation is already widespread. Civil servants and experts across Europe meet regularly in European Administrative Networks (EANs) to share information, develop common standards, and pool resources, ensuring a uniform approach to EU health policy. These networks are not well known to the public, but can be seen as a compromise of an increasing need for cross-border cooperation and a lack of willingness to delegate health care competences to the supranational level.

Through these networks, EU health care policy cooperation is substantial. Over time, a variety of EANs have developed, covering a wide range of issues such as such as orphan medicinal products, health security, human tissues and cells, adverse effects of medicines, medical devices and cross-border health care. A recent well-known example is EMA’s Pharmacovigilance Risk Assessment Committee (PRAC), which is a safety committee of national medicine agencies that monitors and reviews side effects of medicines in the general population and reached headlines as a result of its review of the AstraZeneca vaccine. In our study for the Journal of Common Market Studies, we focus on the rapidly developing field of Health Technology Assessment (HTA). The speed at which new pharmaceuticals and medical devices enter the market increases the need to assess their quality, effectiveness and ‘value for money’. HTAs provide health policy makers with scientific advice upon which they can decide on reimbursement and coverage of such drugs and technologies. With limited health budgets and growing demands, EU cooperation on HTA allows for the pooling of resources, joint assessments and the development of a collective evidence-based approach to deal with the pharmaceutical industry. Pooling of resources at a larger European scale can thus be crucial for the public provision of healthcare. For a large part, these collaborative exchanges take place in EUnetHTA, a voluntary network consisting of expert civil servants acting as representatives from national HTA authorities.


Assessing network structure

The implicit assumption is that such networks are horizontal. Formally, their interactions are on equal footing. However, that is not to say that they are free of hierarchy in practice. In our study we ask ourselves, are network members equally influential in defining the way forward or do some members control and influence the process more than others, and if so, why? Some network members may be more central to the network than others and use this position to push through their preferences and approaches in developing the methods, evidence and procedures for joint HTAs. This is a pressing issue in this case, as a common HTA approach is being developed and a permanent EU HTA network has been under negotiation up until recently.

To examine the network structure of the EUnetHTA, we investigate whether interactions to exchange information, best practices, prepare joint assessments and provide advice are horizontal or whether some member state representative occupy a central position in the network. In a next step, we inspect the factors that explain why some members are more central than others, being it their experience, capacity or external contact relations? To study the network structure and its driving forces, we collected survey data on their interactions and employed social network analysis.


Some are more equal than others

Our findings have several implications for both the study of EU health policy and the more general study of European administrative networks. First, with regard to EU health policy we find that EUnetHTA is considered a very important governance instrument for HTA by its members. The voluntary network for resource pooling can thus be seen as an important forerunner for the soon to be established permanent EU HTA network. Hence, EANs function as important building blocks for the building of a European Health Union.

Second, with regard to European administrative networks more generally, we find that such networks are not quite horizontal in their resource pooling and development of common practices. Instead, the structures in which interaction take place are rather hierarchical. They may not be subject to supranational steering, but some members are able to take on a more central role in the network due to their experience and advancement as regulators on the subject matter. As a result, experienced national regulators can steer the network and push for convergence with their regulatory tradition on a European level. It is not surprising that experienced HTA regulators such as Germany, France and Spain, insisted on maintaining a member-led governance structure for HTA, rather than an increased role for the European Commission in the new and permanent EU HTA network.

It is clear that sitting in the centre of a network is a position of power and that strong regulators may use the opportunity structures of these seemingly horizontal governance instruments to exercise their influence over policy-making and the way forward. While formally all network members are equal, in practice some members may be more equal than others.




About the authors


Reini Schrama is Assistant Professor of Public Administration at the Radboud University Nijmegen. In her research she has advanced the use of social network analysis to study interaction in administrative networks and the functioning of such governance instruments in EU policy implementation.

Twitter: @ReiniSchrama

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Dorte Sindbjerg Martinsen is Professor at the University of Copenhagen, Department of Political Science. Her research focuses on EU welfare policies, investigating integration, national implementation of and compliance with EU social policies, including health care.

Twitter: @dm_martinsen

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Ellen Mastenbroek is Professor of European Public Policy at Radboud University. Her main research interests are the Europeanisation of national governments and EU policy analysis, focusing on compliance, implementation and evaluation of EU legislation.

Twitter: @E_Mastenbroek

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