Public health, free movement and macroeconomic coordination: Mapping the evolving governance of European Union health policy A thesis submitted to Lancaster University in fulfilment of the requirements for the degree of Doctor of Philosophy (Ph.D) in the Faculty of Arts and Social Sciences May 2016 Eleanor Brooks Department of Politics, Philosophy and Religion Table of Contents Declaration ........................................................................................................................ i Acknowledgements .......................................................................................................... ii List of abbreviations and acronyms ................................................................................ iii List of figures ................................................................................................................. vii Abstract ......................................................................................................................... viii PART I INTRODUCTION ..................................................................................................................... 1 The European Union and health ...................................................................................... 2 Health in EU economic governance ................................................................................ 3 Challenges to the established narrative and gaps in the existing research ....................... 5 The research question ...................................................................................................... 6 The structure of the thesis ................................................................................................ 7 METHODOLOGY .................................................................................................................. 10 Aims, objectives and research design ............................................................................ 10 Research tools and methods ........................................................................................... 11 Literature review methodology ............................................................................... 11 Case study methodology .......................................................................................... 12 Interview methodology ............................................................................................ 12 Research limitations ....................................................................................................... 14 CONCEPTUAL AND THEORETICAL FRAMEWORK ...................................................... 16 Conceptual exposition ................................................................................................... 16 Defining integration and Europeanisation ............................................................... 16 Understanding and observing governance ............................................................... 17 Defining and categorising health policy .................................................................. 18 The three stems of EU health policy ................................................................. 19 Technical versus political health policy .................................................................. 20 Theoretical framework ................................................................................................... 21 The theories of European integration ...................................................................... 22 Explaining integration ....................................................................................... 22 Analysing governance ....................................................................................... 23 Constructing the EU .......................................................................................... 23 Theorising consequences ................................................................................... 24 The Europeanisation framework ............................................................................. 24 Theorising EU governance ...................................................................................... 25 Multi-level governance ...................................................................................... 26 Policy networks and epistemic communities .................................................... 26 Globalisation and legitimacy ............................................................................. 26 Deliberative democracy ..................................................................................... 27 New institutionalism .......................................................................................... 27 Making the theoretical framework operational .............................................................. 27 The state of health policy integration ...................................................................... 28 A typology of modes of governance ........................................................................ 29 Research hypotheses ................................................................................................ 30 LITERATURE REVIEW ........................................................................................................ 32 The EU public health literature: 1957-2000 .................................................................. 33 The health and free movement literature: 2001-2009 .................................................... 34 The health and macroeconomic governance literature: 2010-2015 ............................... 36 Post-crisis public health literature ........................................................................... 36 Post-crisis health governance literature ................................................................... 37 Summary ........................................................................................................................ 39 THE HISTORY AND CONTEXT OF EU HEALTH POLICY.............................................. 40 The context of EU health policy .................................................................................... 40 The evolution of the European Union ..................................................................... 40 Policy-making and governance in the EU ............................................................... 42 The EU treaties and the legal basis for health ......................................................... 43 The historical development of EU health policy ........................................................... 44 The genesis of EU health policy: 1957 to 1992 ....................................................... 44 The creation of a public health mandate: 1992 to 1997 ........................................... 45 Crisis, mainstreaming and case law: 1997 to 2008 .................................................. 46 The response to free movement: 2008 to 2011 ........................................................ 47 Economic crisis and contemporary health policy: 2011 to 2015 ............................. 47 Characterisations of EU health policy development ...................................................... 48 Actors in EU health policy ...................................................................................... 49 Processes in EU health policy ................................................................................. 50 The EU health policy bell-curve .............................................................................. 51 PART II REGULATORY POLICY AND CRISIS POLITICS .............................................................. 53 What is meant by blood, tissue and organ policy?......................................................... 53 The historical evolution of EU policy on blood, tissues and organs ............................. 53 Blood contamination crises and public trust ............................................................ 54 EU policy in blood and blood components for transfusion ..................................... 55 EU policy in human tissues, cells and organs for transplantation ........................... 55 The integration and Europeanisation of blood, tissue and organ policy ........................ 56 The governance of blood, tissue and organ policy ........................................................ 57 Horizontal themes in EU health policy: Regulatory policy and crisis politics .............. 59 GOVERNING WITH SOFT LAW .......................................................................................... 62 What is meant by EU cancer prevention policy? ........................................................... 62 The historical evolution of cancer prevention policy in the EU .................................... 62 The Europe Against Cancer programme ................................................................. 62 Cancer policy under the Health Programmes .......................................................... 63 The revival of cancer policy and the EPAAC ......................................................... 64 The integration and Europeanisation of cancer prevention policy ................................ 65 The governance of cancer prevention policy ................................................................. 66 Horizontal themes in EU health policy: The use of soft law ......................................... 68 HEALTH IN ALL POLICIES AND