Building the European Observatory (2/4): From HiTs to Brussels - the model takes shape

Fenton: What was the first real product?

Figueras: The Health Systems in Transition profiles, the HiTs. I had started developing these at WHO before the Observatory formally existed, and they were scaled up substantially around the Ljubljana conference. The idea was simple but ambitious: produce a standardised profile of each health system using a common template, so that policymakers and researchers could compare like with like. By the time we launched, we already had more than thirty completed or underway. They became our calling card. Policymakers loved them because, for the first time, they could see their system described in a structured way and compare it with others.

Fenton: But the HiTs were only one part of the early Observatory work, weren't they?

Figueras: Exactly. The HiTs gave us the country base, but we also needed to compare policy issues across countries. That led to early studies on financing, hospitals, regulation, Central Asia, social health insurance, purchasing, primary care and pharmaceuticals. The point was to take a policy problem and ask: what do different countries do, why do they do it, what are the trade-offs, and what can be learned?

Mossialos: Those books helped establish the Observatory's method. We were not selling a single model. We were developing structured comparative analysis, drawing on country evidence, disciplinary expertise and policy judgement. That approach became the basis for a much larger production of studies, policy briefs and dialogues over the following years.

Fenton: Did you ever think it might not survive those first five years?

Figueras: There were moments. Funding was always precarious. We were building the plane while flying it. But two things saved us. One was the quality of the people. Martin McKee, Richard Saltman, Reinhard Busse, Suszy Lessof and many others brought different perspectives and deep expertise. The other was the demand. Once policymakers started using the HiTs and studies, once ministers and senior officials started calling and asking for advice, the case for our existence began to make itself.

Mossialos: We were very committed and travelling constantly. Natasha Azzopardi-Muscat later wrote about a group of "visionary and passionate young individuals" travelling across Europe to spread the message. That captures something real. We were not waiting in Brussels, Copenhagen or London for the phone to ring. We were out there, building relationships and learning what countries needed.

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Fenton: You have both mentioned London, Copenhagen and later Berlin. The Observatory's hubs seem to have been central from the beginning. Josep, what exactly was a hub, and why did the model matter so much?

Figueras: A hub was not just an office. It embedded the Observatory in academic institutions while keeping it tied to the policy agenda set by the partnership. The first hubs were at LSHTM and LSE, under Martin and Elias. Then came the Spanish hub, at the Spanish National School of Public Health, supported by José María Martín-Moreno, who later became Director of Programme Management at WHO/Europe and played a key role in the Observatory's sustainability. Reinhard Busse then joined the Observatory, first as head of the Spanish hub and later by establishing the Berlin hub at the Technical University of Berlin. Reinhard strengthened the Observatory's work in health economics, quantitative analysis, hospital performance, DRGs and country analysis, and helped develop a new generation of colleagues including Ewout van Ginneken and Dimitra Panteli. The hubs became research platforms and talent pipelines.

Fenton: Elias, from the London side, how did you see the role of the hubs?

Mossialos: The hubs were indispensable. They gave us an academic environment where we could do rigorous work slightly away from the day-to-day pressures of an international bureaucracy, while remaining closely linked to the Observatory's policy priorities and partners. That combination was unusual and powerful.

It also allowed the Observatory to grow people. The London hubs trained colleagues who later took major leadership roles. Jon Cylus, for example, went on to lead the London hubs, while Sarah Thomson led major work on financial protection and later moved to the WHO Barcelona Office for Health Systems Financing. This is another recurring lesson: institutions survive when they create the next generation.

Fenton: Was it around this period that the Observatory moved its headquarters to Brussels?

Figueras: Yes. Moving the headquarters to Brussels and incorporating the WHO European Centre for Health Policy was strategically important. Belgium, Finland and Sweden joined the partnership in that context. Brussels brought us closer to the European Commission, strengthened our work on public health and European policy, and gave us a stronger platform for dissemination and policy impact.

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Fenton: By the mid-2000s, the Observatory was up and running, producing HiTs, building its network. But the European Union was also becoming a major force in health policy. Elias, how did that become part of the Observatory's story?

Mossialos: It was never by accident for us. We had been thinking about the EU dimension from the very beginning, it was central to the book with Abel-Smith, Holland and McKee. But for most people in health policy, the EU was almost invisible. Health was supposed to be a national competence. Member states ran their own systems. Brussels had no business telling them how to organise hospitals or pay doctors. And then the European Court of Justice dropped a bomb.

Fenton: The Kohll and Decker cases in 1998?

Mossialos: Exactly. In 1998, two Luxembourg citizens sought reimbursement for healthcare obtained abroad, one for orthodontic treatment, the other for spectacles. The Court of Justice ruled that EU internal market law could apply to these situations, treating healthcare as an economic activity subject to free movement rules. This challenged the assumption that health systems were purely national. If you could buy a car across borders under single market rules, why not a hip replacement? The implications were significant, and many health ministries were unprepared for the shift.

Fenton: And that is where the Belgian Presidency came in?

Mossialos: In 2001, Belgium held the Presidency of the EU Council. Frank Vandenbroucke, then Minister of Health and Social Affairs and currently Belgium's Deputy Prime Minister, understood that something fundamental was shifting. Frank was unusual among health ministers: he had a strong academic background in social and economic analysis and grasped the implications immediately. He did not need to be convinced that EU law was reshaping health care; he could see it himself. That is why he commissioned the work rather than waiting for the problem to become a crisis. I served as a senior adviser to the Belgian Presidency on precisely this question: what does EU law mean for health systems built on solidarity and universal access?

Fenton: Josep, were you involved in this work?

Figueras: Less directly. This was very much Elias's domain, the intersection of EU law, health economics, and comparative health policy. But from the Observatory's perspective, it was critical. It showed that we were not just describing health systems country by country. We could address the big cross-cutting policy questions that no single country could answer on its own.

Fenton: The study became a book?

Mossialos: It did. Martin McKee and I co-authored EU Law and the Social Character of Health Care, published in Brussels in 2002. The core argument was that EU law was reshaping health systems in ways that many health policymakers had not fully grasped, and that there was a real tension between the market logic of the EU treaties and the solidarity principles underpinning European health care. We were not saying the EU was the enemy of public health, far from it. But we were saying that if health policymakers did not engage with EU law, the courts and the market would shape health policy for them by default. We also published an edited volume, The Impact of EU Law on Health Care Systems.

Fenton: It got attention beyond the usual academic circles?

Mossialos: It did. Michel Rocard, the former French Prime Minister and then a Member of the European Parliament, endorsed it. Having someone of that stature say the work mattered helped it travel beyond the usual health policy circles.

We later produced a much more ambitious follow-up: Health Systems Governance in Europe: The Role of European Union Law and Policy, which I edited with Govin Permanand, Rita Baeten and Tamara Hervey. Cambridge University Press published it in 2010, with a foreword by Koen Lenaerts, then a Judge of the Court of Justice and now its President. That gave the work real authority and showed that our analysis was being taken seriously at the highest level.

The through-line, if there is one, is simple: you cannot separate the technical from the political. Health systems are shaped by economic forces, legal frameworks and institutional incentives that conventional health policy analysis can treat as background noise. Getting that institutional analysis wrong leads to reforms that fail in predictable ways.

Fenton: Was there pushback on any of this?

Figueras: Some. The internal market directorate did not always appreciate being told that its policies had consequences for health equity. And from some health ministries, there was wilful blindness, if they ignored the EU dimension, it would go away. It did not.

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Fenton: You have both stressed analysis. But the Observatory's work was never just analysis. How did the knowledge-brokering side develop?

Figueras: That was a major lesson of the early years. Coming from academia, we initially focused on rigorous, policy-relevant research. But we learned quickly that publication, even policy-relevant publication, is not enough to influence policy. Evidence has to enter the policy process at the right moment, in the right form and with the right people in the room.

So very early on we began developing mechanisms for evidence transfer and knowledge brokering: policy dialogues, policy briefs, rapid evidence responses, tailored presentations to ministries, and closed discussions where countries could explore sensitive issues in confidence. Suszy Lessof, Matthias Wismar and Willy Palm were particularly important in pushing and conceptualising this work. It became core to the Observatory.

Mossialos: That distinction is crucial. A brilliant study that arrives after a decision is useless for that decision. The Observatory's value was that it could combine accumulated evidence with judgement, timing and trust.

Fenton: Looking back at those first five years, 1998 to 2003 or so, what had you achieved?

Figueras: We had survived, for a start. We had proved that the model worked. The HiTs were becoming a standard reference for people trying to understand European health systems. The first comparative volumes were being used by both policy and research communities. The partnership was growing, more governments were joining, we were better integrated with WHO's work, and the European Commission was increasingly engaged. We had also shown that we could tackle politically sensitive questions, such as EU law and health systems, without losing credibility with our partners.

Mossialos: And we had built a team. Martin McKee brought breadth across public health, European politics and research. Richard Saltman brought comparative health systems expertise and a deep understanding of governance. Reinhard Busse brought health economics, quantitative rigour and country analysis. Suszy Lessof was vital in managing the operation, strategy, workplans, governance and collaboration across Brussels, London, Berlin and Copenhagen. The Observatory would not have become what it did without that mix.

Fenton: But still fragile?

Mossialos: Always. Funding was never secure for more than a few years. Any change in political leadership could have threatened our existence. But that precariousness also kept us sharp. We could never take our position for granted.

This is Part 2 of a four-part series on the founding and development of the European Observatory on Health Systems and Policies. Read the other editions here.