Where is the ‘global’ in the European Union’s Health Research and Innovation Agenda?

Introduction

Global Health evolved from the concepts of public1 and international health2 3 to form a ‘system-based, ecological and transdisciplinary approach to research, education, and practice which seeks to provide innovative, integrated, and sustainable solutions to address complex health problems across national boundaries and improve health for all’ (p 155).4 Important components of Global Health include health equity, a focus on health issues transcending national borders, determinants of health, interdisciplinary and international collaboration and a ‘health for all’ approach.2–9

Global Health aims to overcome the national–international divide9 and that between high-income countries (HICs) and low-income and middle-income countries (LMICs) through mutual exchange and partnership, including joint funding, agenda setting, planning and implementation.2 3 10 In doing so, Global Health aims to address the 10/90 gap,11 the disparity between global health research spending and disease burden in LMICs. However, the formation of genuine research partnerships remains a challenge,3 10 12 as does the prioritisation of research targeted at high disease burden populations.2 These challenges are highlighted by the increasing mobility of the global population13 14 and the rapid rise of non-communicable diseases with complex social determinants that require transdisciplinary scientific approaches4,15 and innovative solutions.16,17

This paper emanated from a transdisciplinary meeting of European Global Health research institutes with a non-governmental global development organisation in Brussels in July 2018. The 22 participants in this two-day meeting represented European Global Health researchers from Belgium (University of Antwerp), Germany (Ruprecht-Karls-University, Heidelberg, Ludwig-Maximilians-University, Munich), Italy (University of Milan), Spain (University of Barcelona), Sweden (Lund University), Switzerland (University of Geneva), the Netherlands (University of Amsterdam, University of Leiden, Utrecht University), the UK (Imperial College London, University College London, University of Oxford) and a non-governmental organisation (NGO) for global development, Deutsche Stiftung Weltbevölkerung (DSW). A Future Search Conference methodology18–20 was used to assess developments in Global Health at individual institutions, across Europe and globally. With the European Commission publishing a new European Research and Innovation (R&I) Framework, Horizon Europe, participants analysed European health R&I priorities based on Global Health challenges and with the aim to strengthen Global Health considerations in this framework. Negotiations between the Council of the European Union (EU) and the European Parliament led to modifications in the Horizon Europe Framework. The negotiating process was informed by the positions of various actors—private sector, NGOs and academic institutions—including that of the European Global Health Research Institutes Network (EGHRIN), a network formed at the Brussels meeting in July 2018, see https//eghrin-eu. To illustrate important text and structural changes in Horizon Europe with regard to Global Health, this paper refers to the initially proposed framework and regulation documents by the European Commission of June 201821–24 as well as subsequent versions in late 201825 26 leading to the documents agreed on by EU institutions and approved by the European Parliament in April 2019.27 28 The EU R&I Framework is analysed and appraised from a Global Health perspective and with reference to the Sustainable Development Goal (SDG) framework.29

EU efforts on Global Health in the last decade

Global Health came to prominence on the European agenda with the EU‘s first health strategy and policy framework in 2007 and Council Conclusions on Global Health in 2010.30 The 2010 Council Conclusions set out to advance a visionary Global Health agenda focused on strengthening collaborative research capacity; developing affordable medical products; dissociating Research & Development (R&D) costs from intellectual property considerations; ensuring that access to knowledge and tools form part of the R&D agenda; and strengthening health systems to measure progress on the social determinants of health.31 Yet, instead of being the starting point for greater Global Health research engagement, the EU Communication and Council Conclusions largely remained a statement rather than a plan for action30 and few member states developed their own Global Health policies.32

The EU Communication on its role in Global Health33 emphasised the aspect of ‘protection against Global Health threats’ (p 2). Protection was, however, mainly defined in terms of strengthening ‘global and third countries’ national capacities of early prediction, detection and response to Global Health threats’ (p 8) rather than focusing on cross-border health threats, which became more prominent in recent publications of the EU.27,34 This led to the question of whom health security is for35 36 or even what it should entail37 or how ‘security’ should be defined and specified.38 Global Health strategies with a self-interested security concern can also be perceived in the policies of member states such as the UK, Germany and France.32 Security concerns relate to a regionalisation of local epidemic outbreaks, the threat of terrorism from impoverished regions, and conflict over resources due to climate change, to name a few.39 The heightened concern for security and the persistent after-effects of the 2008 financial crisis led to Europe’s 2020 strategy, which focused primarily on job creation and economic growth.40

Germany used its presidencies of the G7 and G20 summits in 2015 and 2017 to give more prominence to Global Health.41 42 Yet, Global Health has largely fallen off the EU research agenda.22 27 28

New European R&I Framework—Horizon Europe

Horizon Europe lists health as one of six clusters in ‘Global Challenges and European Industrial Competitiveness’,27 the second pillar of the programme. The other two pillars are ‘Excellent Science’ and ‘Innovative Europe’,27 see figure 1. The health cluster is divided into six priority areas: health throughout the life course; environmental and social health determinants; non-communicable and rare diseases; infectious diseases, including poverty-related and neglected diseases (PRND); tools, technologies and digital solutions for health and care, including personalised medicine, and healthcare systems.28

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Horizon 2020 is the EU’s current R&I Framework Programme (2014–2020) with a budget of €80 billion34 43 with 10% earmarked for health.34 The European Commission proposed the successor programme Horizon Europe in 2018, with a budget of €94.1 billion for 2021–2027 including €7.7 billion, or 8%, earmarked for health.23 The draft documents were discussed by the Council of the EU and the European Parliament and altered with some improvements on Global Health language and concepts27 28 while at the same time emphasising European innovations, see figure 1. The Council upheld multidimensionality in addressing global challenges, among others through R&I missions,25,28 yet did not increase the budget proposal of the European Commission of €94 billion. Contrary to the Council, the European Parliament proposed an overall research budget for Horizon Europe of €120 billion,26 with the health cluster receiving 8.16% or €9.79 billion of the overall budget.44 The budget was not part of the final Horizon Europe Framework of April 2019 and will be negotiated as part of the multiannual financial framework in 2019.45

Analysis of EU R&I Framework

What follows is a European Global Health institutes’ analysis of Global Health issues in the current and previous Horizon Europe frameworks.21–24 27 28 46 47 SDGs and industrial competitiveness and innovation, which are central themes in the Horizon Europe Framework, are also considered in this analysis. Further themes such as funding, health systems, environmental and social health determinants and more detailed information on Global Health, PRND, LMICs, networking and participation are listed in the online supplementary table 1.

A vision for Global Health research

In a global and interlinked world, there is a need for equitable,10 well-funded innovative health research between LMICs and HICs79 that addresses interconnected health issues: climate change; migration; access to food and water; the spread of diseases and epidemics; the development of new, needed and affordable diagnostics and medicines; and the strengthening of health systems to significantly decrease the global disease burden49 and to improve health equity while ensuring consistency between (European) health and trade policies.7,39,80 Such R&I could be a catalyst for the implementation of the SDGs and a move towards a One Health and eventually a Planetary Health approach.6 Global Health research and cost-effective solutions would also benefit HICs, such as European member states, that increasingly struggle with high medicine prices and an overstretched work force, a problem well-known to LMICs.73,74 79 In order to devise global solutions to global problems, cooperation not only needs to involve LMICs but also extend beyond research institutions to civil society (eg, NGOs) and governments.4 This would ensure that key stakeholders have a voice in the R&I agenda and facilitate implementation at the national level while strengthening a transdisciplinary research approach. The equitable cooperation of research institutes globally is also a crucial element for advancing Global Health research, yet should take the key element of governance into account.81 This vision of equitable research in Global Health supported by the EU is based on the Decision document, which foresees improved pan-European and regional collaboration.27 Yet, further globalisation of this vision is needed to enable institutions in LMICs to better access direct funding for health R&I and to lead on much needed research in Global Health. This could also be achieved through a strengthening and widening of the EU partnership programme EDCTP as well as Global Health research networks.

Conclusion

The discussion and analysis of the proposed Horizon Europe R&I Framework by European researchers engaged in Global Health confirmed the importance of the EU and this framework for health R&I, yet found it wanting in terms of a genuine Global Health approach despite some improvements to the framework during the negotiating process. European industrial interests were found to dominate with regard to Global Health innovations; LMIC participation, by contrast, is hardly mentioned in the framework.

Aluttis and colleagues30 in analysing Global Health in relation to the EU remark that ‘the EU remains a forceful actor in the world which can speak with a strong voice on health matters of global concern’ (p 6). In order to maintain this role, the EU will need to fully embrace the concept of Global Health in the implementation of its R&I agenda and facilitate and adequately fund joint Global Health research to ensure that health innovations benefit all parts of the world. Special Horizon Europe funding calls with an intent to increase participation of LMIC research institutes could directly benefit the EU through effective and cost-saving innovations in and from LMICs and their transfer to Europe. The EU would therefore benefit from strengthening partnership programmes such as EDCTP or by facilitating funding for global research networks that include research institutions based in LMICs and work in a transdisciplinary way with equitable governance structures.

Applying a Global Health concept and strategy to the framework would show effects beyond health, as Speakman and colleagues82 comment: ‘A prominent EU Global Health strategy would not only benefit Global Health. It would also show leadership from Europe, promoting the values of which the EU is justifiably proud: respect for human dignity and human rights, freedom, democracy, equality…’ (p e393). An enhanced EU strategy on Global Health could help invigorate world class health research with tangible Global Health outcomes and sustainable Global Health innovations for coming generations.