Multilateralism Key To Addressing Many Health Issues, Austrian Health Official Says

BAD HOFGASTEIN, Austria — For many health issues, individuals and nations must work together to achieve solutions, Clemens Martin Auer, the director general of the health ministry of Austria, said in an interview with Health Policy Watch. And the annual European Health Forum Gastein is a good place to talk about it, he said. This is part one of a two-part interview.

Austrian Health Ministry Director General Clemens Auer addresses the European Health Forum, Gastein

“The European Health Forum and other settings like this are very important, they demonstrate how important it is to think in larger entities and to step out of silos,” he told Health Policy Watch in an interview in Gastein. “Silos can be many things, such as national constraints. I’m working in a ministry of health, do I talk to the ministry of science? If you want to get something accomplished you have to talk to people in the other departments. This is also true for countries, this is true for industry, true for NGOs, for almost everyone.”

Multilateralism is not – with the major exception of Brexit – under threat in Europe, he argued. But, he said, “there are world leaders out now who think multilateralism is a bad thing, you know, because it’s about patriotism. I’m not saying anything against patriotism. But the way these guys read that, they’re stuck in their silos. The United States is a pretty big silo. But even this big silo does need other silos.”

The renowned Gastein conference, held annually in a ski town in the Alps above Salzburg replete with natural hot baths, took place on 3-5 October. Perhaps relevant, the overall message of this year’s conference was to “Think big, be bold, be practical.”

Auer said the conference is “not about problem-solving, it’s about awareness-raising, but gives food for thought. It allows you to go home and say, we have a problem here, and I understood the problem a little bit and what other people think about the problem, and then you can do accordingly, start working on the solution.”

From a political standpoint, “there are certain things you cannot solve alone,” Auer continued. For instance, with noncommunicable diseases (NCDs), “you cannot solve alone the problem of obesity,” he said, adding: “We cannot solve the problem alone in Austria, you cannot solve the problem alone in Switzerland, not even Germany can solve the problem alone. There are so many factors that influence this kind of thing which are unsolvable if you do it in your own silo.”

He said: “We have to look – and the health sector is not very well prepared to do so – we have to look at social determinants, and we are looking at them a little bit, but also economic, and fiscal determinants of the health sector. Why is it that certain companies produce certain things? It’s not because they want to harm people, if it comes to sugar in beverages. I don’t blame any of the multinational companies. They are global companies, they do it because they are making profit out of it. They have a product on the market that in the long term has a negative effect on people.”

“How can you solve this problem?” he asked. “Talking to the company of course. You have to raise the awareness first. You might talk and if they don’t change then you can regulate [more effectively at the EU level].”

And despite having discussed NCDs “all over, many, many times,” not much has been achieved, he said. Why? “Because the health sector stayed in the health silo.”

Asked about the so-called open spirit of the Gastein conference, away from the intensity of the capitals, he said ideally it would be the case that people speak openly, but as with any conference “that rarely happens.” However, a key aspect of the event – not on the official programme – are side events behind closed doors where high level decision-makers can exchange views in a safe setting under Chatham House rules.

This year there were several hours for high level attendance during the event, and a topic of discussion was subsidiary principles in the European Union as it relates to health, and how they tackle that, he said.

Under subsidiary principles it is agreed to solve problems at the lowest possible level, and that the EU bodies are only allowed to do what they are delegated to do. Health is an area where the treaties have put limits on what can be done at the European Union level, he said.

Asked for examples of things that are working in health policy and some that need work, he answered that rare diseases – if one looks at the clinical part of the story – are a good example where silos don’t work. “If you have few patients, you cannot develop the expertise,” he said. “For instance, Austria may have 5 patients, whereas the EU may see 500 patients, then you can develop the expertise needed to do the research.”

This is happening now, he said, adding that the reference networks on rare diseases which are laid out in the cross-border health directive of 2011 is a best practice example of an added value of European collaboration.

It is also possible to see in the e-health sector, exchanging certain data across borders, Auer said, noting, “The added value is the enriching of national discussions, because if the standard is sharing of health data regionally then it is also the case nationally.”

But there, he said, “we could probably do better, we still haven’t found the formula for standards, technical and semantic standards, we haven’t put into a fixed framework in Europe. We agree that we have to do it, but we haven’t done it yet. Without standards and formats and semantic interoperability, you cannot create a digital health ecosystem throughout Europe.”

Succeeding in bringing policies about “always boils down to leadership, someone has to take the lead, others have to be willing to follow,” said Auer. “This is the secret of everything on that level of work.”

Asked if he has taken on the leadership role, he said has taken leadership on e-health and digitalisation, where they are “doing quite a bit” in the country and at the EU level. “I would like to influence standards and formats we are using here,” he said.

He said that in the best practice in rare diseases, there were a handful of researchers. “We have overcome the limitations of our small worlds, the hospital or academic world, and we have created this reference network, which is really something,” he said.

Keeping Health High Among EU Priorities

Austria is currently in the six-month rotating presidency of the European Union. And as the EU prepares for its next five-year plan, there is chatter that health issues might be diffused across other competencies. Auer downplayed this.

“We are talking about rumours now,” he said. “The rumour is – and there is always a reason for the rumours – that within the European Commission, the DG [directorate general] Sante, which has responsibility for health and consumer protection, has not a strong standing and there are forces within the Commission to divide it up and integrate the dossier into other DGs.”

The health directorate has certain competencies, he noted. For instance, he said, “market authorisation was always in DG Competition, and it took the health ministers and the health sector a long time to move that into the competencies of DG Sante because the market authorisation of medicines is not only about jobs and growth, and competitiveness in the interest of certain companies.”

Medicines are not a commodity like a car or a television set – Minister Auer

“Medicines are not a commodity like a car or a television set,” said Auer. “It has a different value politically speaking. So it makes sense that there is a unit within the European Commission that takes care of health issues.”

The rumour says they want to “dismantle” DG Sante, he noted. In addition, EU President Juncker has published his four options for what the future of the European Union should be. “Among the member states, there is a high popularity for what is called option 4, which says, do less but more efficiently,” Auer said. “Or as I think President Juncker has said, do big things for big problems, and small things for the smaller problems.”

For health, Auer sees that there is “a magnitude of issues you can solve locally, regionally and nationally. But there’s also a magnitude of issues which you can’t.” Examples he gave are NCDs, medicines, medical devices, standardisation of digital devices, or “creating a European-wide digital ecospace.”

“If it is an overhaul of the training and education of health workforce in Europe, you can’t do that nationally all alone, so doing less and more efficiently doesn’t play there,” he argued. “In the health sector … we are in the process of building an awareness that we are losing something if you lose this coordinating mechanism on the European level. And that is what the discussion is all about.”

Auer said he stressed at the opening of the Gastein conference that “we have to talk about limitations of subsidiarity and be very clear what are the issues we have to tackle together. It’s not about the details in the reimbursement system. It’s not about the details of how to set up primary healthcare infrastructure in the Gastein Valley. This is definitely something that three or four villages in the valley have to take care of.”

When it comes to regulating sugar in beverages, the four townships here [in the Gastein Valley] are powerless – Auer

“But when it comes to regulating sugar in beverages, the four townships here are powerless,” he said. “They cannot regulate the sugar content in beverages. Not even the regional government down in the city of Salzburg. Not even the national government in Vienna.  But we can do that on a European level.”

Global Health – SDGs Reframe Discussion

Asked about the global health level, he said he sees the global debate as coming out of the United Nations mainly in relation to the Sustainable Development Goals for 2030, and that the global discussion is helpful not only for the global level but also for the regional, national and local levels.

The discussion on Sustainable Development Goals has the potential – we are not there yet – to reframe the political understanding we had in the last 20-30 years

“As political analyst, I would like to say that the discussion on Sustainable Development Goals has the potential – we are not there yet – to reframe the political understanding we had in the last 20-30 years,” he said. That’s because “the political understanding, at least in the western hemisphere, in the industrialised world, was that each and everything governments and national competitive authorities do is to strengthen competitiveness of regional, local, national industry in the merciless fight for market share in the global market. This is such a strong narrative.”

“If you talk to people in industry, they say, ‘look at China, they are so much faster, we have to reduce our costs’,” he noted. “And the Sustainable Development discussion says, ‘Stop it.’ Yes of course it’s about globalization, yes it’s about sustainable development for jobs and growth. But there are so many other factors entering into the picture.” These include social cohesion, environment, education, the basic needs of people, and it is true for the whole world, he said, adding, “This is not only a European topic, or a North American topic.”

“We have to change how we conduct business, how we produce products, how we use them, how we pollute the air, how we use the resources, how we treat people, how we set up healthcare systems, how we guarantee access to healthcare,” Auer said. “In that way, I think the United Nations really started, and I think Ban Ki-moon has to be granted a Nobel Prize for that, he started the discussion on this at the diplomatic level, the heads of state and heads of government several years ago were able even to agree on them.

We have to change how we conduct business, how we produce products, how we use them, how we pollute the air, how we use the resources, how we treat people, how we set up healthcare systems, how we guarantee access to healthcare

“That was a big achievement,” he stressed. “People like me or others now have a narrative we can build on. ‘Ok, this is what the General Assembly of the United Nations together voted on and agreed on, and let’s work accordingly’, even if there are presidents sometimes from big countries who are not capable intellectually to even understand what it is about.”

The industry-first narrative doesn’t work anymore, said Auer. “It’s working for a few people,” he said. “If you look at OECD statistics for the ‘industrialized’ world, we are already noticing that we are losing middle-skilled jobs, at least in Europe and North America, and we should think about things like that.”

“It’s fine if they are compensated in other regions of the world, but we have to think politically about that, what does it do to our societies and how can we compensate it, what programmes do we have to initiate to do so,” he said.

The big advantage of the Sustainable Development Goals discussion is that they have a holistic approach, he added, noting that the 17 goals of the SDGs cannot be isolated, they are all interdependent.

“Have we achieved a lot? No. That’s the beginning of a discussion. Have we changed a lot? No, not yet,” said Auer. “But all of a sudden, we are getting reports, benchmarks, some member states of the UN are starting action plans they have to implement or at least are doing some reporting, that’s the easiest thing.”

For Europe, it is probably very easy to report on that because they “formally and in quantity reach many of these goals,” he said. “But if you look, you see that even in Europe we have problems. Take a little topic, co-payments for medicines. Do co-payments have a catastrophic effect on household incomes of low-income people, yes or no? Do we even know that? Now we are starting to look into it. It turns out we are learning yes, in some countries it does have an effect if you have higher co-payments for cancer drugs, for example. This is a barrier to equal access.”

On political changes in some European countries, such as France, he said the marketplace is at the centre of the debate over these issues, and in the case of France, the French law may have been an “archaic” law.

But to those who are moving toward eroding health benefits, he said, “They will lose.”

“The health sector has the advantage that everyone is affected by it, and people will notice it, and then they will find out that this was a bad policy decision,” he said. “I don’t underestimate that people have a very good feeling for social cohesion.”

“The danger here,” he said, “is that this ‘leapfrogs’ (referring to a word from the discussions in Gastein) into political frustration, and people are so disappointed that they are going after extremes, and my observation is the extremes are not capable of solving the problems.”


Image Credits: William New.

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