Enlargement health check: Which EU hopefuls are fittest?

Countries aspiring to join the EU have significant work ahead to meet the bloc’s health standards, which involve aligning with the EU’s complex health regulations.

As Commissioner Olivér Várhelyi, who is tapped to take on the role of Health Commissioner in the next mandate, put it: “Enlargement is among the top three issues our leaders are discussing nowadays.”

This year’s evaluation of candidate countries’ progress toward becoming EU members sheds light on the health-related reforms still needed for EU alignment.

Many candidates must still adapt national frameworks to EU standards, including digital health infrastructure, prevention programs, and regulations on tobacco and alcohol.

The pace of progress in health regulation harmonisation offers a clear gauge of each country’s readiness for EU membership.

Long road ahead: Albania, Bosnia, Kosovo

For Albania, Bosnia, and Kosovo, alignment with EU health standards is still in its early stages, indicating a long journey ahead.

Bosnia and Herzegovina showed no significant progress in 2024, particularly struggling to align its framework with EU tobacco control laws and enforce them, according to the EU executive.

Additionally, Bosnia’s limited participation in the European Centre for Disease Control and Prevention (ECDC) technical activities hinders its integration into the EU agency system.

The country report points out that corruption in Bosnia’s health sector, particularly exposed during the pandemic due to irregularities in medical procurement, remains a barrier to effective healthcare delivery.

Albania faces challenges in strengthening its healthcare workforce and infrastructure, particularly in primary care, where citizens often resort to private healthcare due to limited public options.

Progress has been made with the participation of Albanian entities in the EU’s Critical Medicines Alliance and the adoption of a mental health action plan in 2023. However, a national cancer registry is still missing, and bans on smoking in indoor public spaces are weakly enforced – with the EU recently recommending member states extend them to certain outdoor areas.

Kosovo faces similar obstacles, including an underdeveloped health financing system, which limits access to universal health coverage. With no effective strategic purchasing mechanism, Kosovo’s health services remain inefficient, and inequalities in health outcomes persist.

However, Kosovo has made progress in patients’ rights in cross-border healthcare and implemented a cancer screening program, although checks are not systematic, and the country also lacks a cancer registry.

Room for improvement: Moldova, Ukraine

Moldova and Ukraine demonstrated “some level of preparation in health protection” for the Commission, though substantial improvements are needed.

Ukraine is in a particular situation, EU’s top diplomat Josep Borrell explained presenting the enlargement package: “Ukrainians are fighting two battles at the same time: A real war on the battlefield and another to push the reforms needed to become a member of the EU. And we will support Ukraine on both fronts.”

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Facing the challenges of war, Ukraine has still managed to make some progress in health reform, including cancer prevention initiatives and measures against communicable diseases.

Nevertheless, Ukraine lacks a comprehensive national health strategy and action plan, and health resources remain insufficient to meet the country’s needs.

In Moldova, the health system remains fragile post-COVID-19 and amid ongoing refugee and energy crises. A national health strategy aims to modernise Moldova’s health sector by 2030, and the country has launched screening programs for breast, cervical, and colorectal cancers.

However, corruption in healthcare remains widespread, despite anti-corruption initiatives, with the Commission also advising Moldova to improve healthcare quality.

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Top tier: Montenegro, North Macedonia, Serbia

North Macedonia, Montenegro, and Serbia were considered moderately prepared, having achieved key progress in EU health rules alignment.

Serbia, for instance, has updated its health records legislation to comply with EU data protection laws, although tobacco control enforcement and childhood vaccination awareness require improvement. Community-based mental health services in Serbia also remain underdeveloped with low accessibility.

Montenegro showed a good level of preparedness, supported by its healthcare development strategy (2023-2027) adopted in October 2023 and recent investments in IT infrastructure to improve service accessibility and quality of healthcare services. In early 2024, Montenegro even signed an association agreement to join the EU4Health program, seen as a promising step toward integration.

North Macedonia, though also well-prepared, faces challenges in funding and staffing, according to the report. The country has fewer specialists and nurses per capita than the EU average, and healthcare workers often leave the public sector for private roles or work abroad.

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Straight-A candidate: Türkiye

Türkiye stands out as the best-prepared hopeful for EU accession on its health criteria alone. Despite setbacks from the February 2023 earthquakes, Türkiye has made significant progress in managing cross-border health threats and communicable diseases.

The country’s mental health de-institutionalisation policy has led to the establishment of 182 community mental health centres across the country.

However, the Commission notes that barriers to reproductive healthcare for women remain, due in part to societal norms. Türkiye also leads the European region in living organ donation, although deceased donor rates remain low.

The EU’s relationship with Türkiye is complex, with Türkiye showing limited recent interest in formal EU membership and exploring different geopolitical paths.

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“We had tried to reengage in our relations with Türkiye and concrete steps were taken towards a constructive exchange on issues of joint interests. That’s what we will continue trying to do,” said EU’s top diplomat Borrell.

Health cooperation has continued, for instance, as highlighted in the 2024 EU-Türkiye High-Level Dialogue on Health in Ankara from April 2024, which emphasised joint efforts on cross-border health threats, cancer care, mental health, and climate-related health impacts.