Skip to main content
Log in

Inside the black box: The EU’s economic surveillance of national healthcare systems

  • Original Article
  • Published:
Comparative European Politics Aims and scope


In the context of macro-economic surveillance, the European Union(EU) increasingly addresses national health system reform. Member States receiving financial assistance are required to implement detailed reforms stipulated in ‘Memorandums of Understanding’ (MoUs). But the health systems in other (non-MoU) countries are also scrutinised in the context of the ‘European Semester’: through this annual policy cycle, the EU has continuously strengthened the tools it uses to enforce compliance. This article aims to open the black box of the EU’s economic surveillance of national healthcare systems by outlining the complex policy architecture of the EU’s newly acquired role in this area. The story of how health has emerged on the European agenda illustrates how the Eurozone crisis created a policy ‘window of opportunity’ to push through fiscal surveillance of health systems as part of the solution to the crisis. The cognitive frameworks put forward by certain elites added up to the primacy of an economic perspective over health objectives. Finally, our analysis of the role of the actors involved in the elaboration of EU guidance in the field of health points to the dominance of ‘economic’ actors and relative absence of ‘health’ actors, in spite of increased attempts by the latter to gain influence.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Figure 1

Similar content being viewed by others


  1. Article 168,7° of the Treaty on the Functioning of the European Union.

  2. Council Regulation (EC) 1466/97; Council Regulation (EC) 1467/97; Council Regulation (EC) 479/2009; Regulation (EU) No 1173/2011 and Directive 2011/85/EU.

  3. Regulation (EU) No 472/2013 and Regulation (EU) No 473/2013.

  4. Treaty on Stability, Coordination and Governance in the Economic and Monetary Union, between the Kingdom of Belgium, the Republic of Bulgaria, the Kingdom of Denmark, the Federal Republic of Germany, the Republic of Estonia, Ireland, the Hellenic Republic, the Kingdom of Spain, the French Republic, the Italian Republic, the Republic of Cyprus, the Republic of Latvia, the Republic of Lithuania, the Grand Duchy of Luxembourg, Hungary, Malta, the Kingdom of the Netherlands, the Republic of Austria, the Republic of Poland, the Portuguese Republic, Romania, the Republic of Slovenia, the Slovak Republic, the Republic of Finland and the Kindom of Sweden, Brussels, 2 March 2012.

  5. The European Structural and Investment Funds are: European Regional Development Fund (ERDF), European Social Fund (ESF), Cohesion Fund (CF), European Agricultural Fund for Rural Development (EAFRD) and the European Maritime and Fisheries Fund.

  6. The EPC contributes to the work of the Economic and Financial Affairs (ECOFIN) Council and the Commission by developing analysis and policy consensus.


  • Azzopardi-Muscat, N., Clemens, T., Stoner, D. and Brand, H. (2015) EU country specific recommendations for health systems in the European semester process: Trends, discourse and predictors. Health Policy 119(3): 275–383.

    Article  Google Scholar 

  • Baeten, R. and Thomson, S. (2012) Health care policies: European debate and national reforms. In: D. Natali and B. Vanhercke (eds.) Social Developments in the European Union 2011. Brussels, Belgium: European Trade Union Institute and European Social Observatory, pp. 187–212.

    Google Scholar 

  • Council of the European Union (2010) Council Conclusions on the EPC-Commission Joint Report on Health Systems in the EU, 3054th Economic and Financial Affairs Council Meeting, Brussels, Belgium, 7 December.

  • Council of the European Union (2013) Council adopts cohesion policy package for 2014–2020, Brussels, Belgium, 16 December, 17826/13.

  • Council of the European Union (2014) Outcome of proceedings, Terms of reference for an expert group on health systems performance assessment, Brussels, Belgium, 9 September, 12945/14.

  • De la Porte, C. and Heins, E. (2015) A new era of European integration? Governance of labour market and social policy since the sovereign debt crisis. Comparative European Politics 13(1): 8–28.

    Article  Google Scholar 

  • Dolvik, J.E. and Martin, A. (2015) European Social Models From Crisis to Crisis. Employment and Inequality in the Era of Monetary Integration. Oxford: Oxford University Press.

    Google Scholar 

  • European Commission (2014) Identifying fiscal sustainability challenges in the areas of pensions, healthcare and long-term care policies, European Economy, Occasional Papers No. 201. Brussels, Belgium.

  • European Commission and EPC (AWG) (2010) Joint Report on Health Systems, European Economy Occasional Papers No.74. Brussels, Belgium.

  • European Council (1997) Resolution of the European Council on the Stability and Growth Pact, Amsterdam, 17 June, Official Journal C 236, 2 August, pp. 1–2.

  • Fahy, N. (2012) Who is shaping the future of European health systems? British Medical Journal 344(e1712): 4.

    Google Scholar 

  • Greer, S.L. (2014) The three faces of European Union health policy: Policy, markets and austerity. Policy and Society 33(1): 13–24.

    Article  Google Scholar 

  • Greer, S.L., Fahy, N., Elliott, H.A., Wismar, M., Jarman, H. and Palm, W. (2014) Everything You Always Wanted to Know About European Union Health Policies But Were Afraid to Ask. Denmark: World Health Organization, 2014 on behalf of the European Observatory on Health Systems and Policies.

    Google Scholar 

  • Greer, S. and Löblová, O. (2016) European integration in the era of permissive dissensus: Neofunctionalism and agenda-setting in European health technology assessment and communicable disease control. Comparative European Politics.

  • Hassenteufel, P. and Palier, B. (2015) Still the sound of silence? Towards a new phase in the Europeanisation of welfare state policies in France. Comparative European Politics 13(1): 112–130.

    Article  Google Scholar 

  • Helderman, J.K. (2014) The crisis as catalyst for reframing health care policies in the European Union. Health Economics, Policy and Law 10(Special Issue 1): 45–59.

    Google Scholar 

  • Ioannidis, M. (2014) EU financial assistance conditionality after ‘two pack’. Zeitschrift für ausländisches öffentliches Recht und Völkerrecht 74(1): 1–44.

    Google Scholar 

  • Kingdon, J.W. (1995) Agendas, Alternatives and Public Policies. New York: Harper Collins.

    Google Scholar 

  • Mossialos, E., Permanand, G., Baeten, R. and Hervey, T. (eds.) (2010) Health Systems Governance in Europe: The Role of European Union Law and Policy. Cambridge, UK: Cambridge University Press.

    Book  Google Scholar 

  • Natali, D. (2010) Pensions in turmoil owing to the crisis: Key messages from the EU. In: C. Degryse (ed.) Social Developments in the European Union 2009. Brussels, Belgium: ETUI/OSE, pp. 119–148.

    Google Scholar 

  • Pavolini, E., León, M., Guillén, A.M. and Ascoli, U. (2015) From austerity to permanent strain? The EU and welfare state reform in Italy and Spain. Comparative European Politics 13(1): 56–76.

    Article  Google Scholar 

  • Pisani-Ferry, J., Sapir, A., Guntram, B. and Wolff, G.B. (2013) EU-IMF Assistance to Euro Area Countries: An Early Assessment. Brussels, Belgium: Bruegel.

    Google Scholar 

  • Reeves, A., McKee, M., Basu, S. and Stuckler, D. (2014) The political economy of austerity and healthcare: Cross-national analysis of expenditure changes in 27 European nations 1995–2011. Health Policy 115(1): 1–8.

    Article  Google Scholar 

  • Scharpf, F.W. (2002) The European social model. Journal of Common Market Studies 40(4): 645–670.

    Article  Google Scholar 

  • Schmidt, V. (2015) Forgotten democratic legitimacy: ‘Governing by the rules’ and ‘ruling by the numbers’. In: M. Matthijs and M. Blyth (eds.) The Future of the Euro. Oxford: Oxford University Press.

    Google Scholar 

  • SPC (2015) Progress Report on the review of the Joint Assessment Framework in the area of health. SPC/2015.2.2/4.1, Brussels, Belgium, 17 February.

  • Stamati, F. and Baeten, R. (2015) Healthcare reforms and the crisis, ETUI Report 134, Brussels, Belgium, ETUI, p. 96.

  • Theodoropoulou, S. (2015) National social policy and labour market reforms in the shadow of EU bail-out conditionality: The cases of Greece and Portugal. Comparative European Politics 13(1): 29–55.

    Article  Google Scholar 

  • Thomson, S. et al (2015) Economic crisis, Health Systems and Health in Europe. Impact and Implications for Policy. Berkshire, England: Open University Press, European Observatory on Health Systems and Policies Series.

    Google Scholar 

  • Verdun, A. (2015) A historical institutionalist explanation of the EU’s responses to the Euro area financial crisis. Journal of European Public Policy 22(2): 219–237.

    Article  Google Scholar 

  • Vollaard, H. and Martinsen, D.S. (2016) The rise of a European healthcare union. Comparative European Politics.

  • Zeitlin, J. and Vanhercke, B. (2015) Economic governance in Europe 2020: Socialising the European semester against the odds? In: D. Natali and B. Vanhercke (eds.) Social Policy in the European Union: State of Play 2015. Brussels, Belgium: European Trade Union Institute and European Social Observatory, pp. 65–95.

    Google Scholar 

Download references

Author information

Authors and Affiliations


Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Baeten, R., Vanhercke, B. Inside the black box: The EU’s economic surveillance of national healthcare systems. Comp Eur Polit 15, 478–497 (2017).

Download citation

  • Published:

  • Issue Date:

  • DOI: