EUROPEAN COMMISSION Brussels, 15.6.2021 COM(2021) 380 final COMMUNICATION FROM THE COMMISSION TO THE EUROPEAN PARLIAMENT, THE EUROPEAN COUNCIL, THE COUNCIL, THE EUROPEAN ECONOMIC AND SOCIAL COMMITTEE AND THE COMMITTEE OF THE REGIONS







Drawing the early lessons from the COVID-19 pandemic



1.INTRODUCTION The world continues to grapple with an unprecedented public health crisis, which has taken an unspeakable toll on human life, put societies under enormous strain and sparked one of the most acute global economic challenge in modern history. As vaccination rates continue to go up and infection rates go down in Europe, the EU has put in place a set of measures and coordination to confront the pandemic and ensure that the impact on our societies and economies is alleviated. At the same time, the risks of COVID-19 are still high and daily global infection levels are more than twice what they were this time last year. This reflects the fact that, despite the progress, the pandemic is not yet over. But it also shows the need and the urgency to continue learning the lessons of this crisis in order to better address the new and emerging threats of this pandemic, while also preparing for new and different health crises in the future. This Communication therefore focuses on some of the early lessons in the field of health that Europe needs to act upon now. It is by design – and by necessity – an interim report and provides a basis on which more lessons will be drawn in the longer term. Any exercise of this nature must start with a critical look at what has been done, what has worked well and what has not. It needs to acknowledge that without the skill and selflessness of so many front line workers, the situation would undoubtedly have been even more difficult. It should also acknowledge the uneven impact of the crisis, with vulnerable groups amongst the hardest hit. This honest assessment is essential if real lessons are to be drawn at policy and political level. It can help identify where weaknesses and fragilities have been exposed, where preparedness and response systems and cultures have to be strengthened and where emergency solutions can be built on or made permanent. The underlying truth is that just like almost every region and country across the world, neither the EU nor the Member States were ready for this pandemic. Preparedness and planning were exposed as being under-funded and under-developed and much of the EU response had to be ad hoc and temporary. Coordination and cooperation between Member States was often initially difficult and took time to get established and start functioning. This cost valuable time in the early stages of the pandemic and shows that the right structures were not in place. At the same time, the EU’s response to the evolving pandemic has included a wide range of unprecedented initiatives that were designed and delivered in record time. This, above all, saved lives, livelihoods and brought help to health services. It also demonstrated the added value and need to work together as Europeans when it comes to pandemics or other cross-border threats, whether through emergency response, vaccines, procurement, the production of essential goods, or leadership and effective support for global efforts. The EU’s action to mitigate the risk of major economic recession was swift, effective, and well-coordinated from the start. It relied on a combination of triggering existing crisis response mechanisms and the mobilisation of huge resources. This response drew heavily on the lessons learned since the financial crisis that started in 2008. Learning from experience, the EU – Member States and EU institutions – took swift and resolute action to protect the economy when crisis struck in 2020. The monetary policy decisions and forward guidance from the European Central Bank, which have preserved favourable conditions for all sectors of the economy, and actions by supervisory authorities, have also been indispensable. HOW TO LEARN LESSONS: WHAT THE ECONOMIC RESPONSE TEACHES US ABOUT CRISIS PREPAREDNESS The EU took decisive action to tackle the economic fallout of the pandemic. This drew heavily on the experience and arrangements built to address previous challenges and crises in the economic and financial area. However, it was clear from the outset that we were faced with a once-in-a-century challenge. A trusted three-step approach: -First, the EU took emergency steps to mobilise EU resources, including €82 billion from the EU budget (including the Coronavirus Virus Response Investment Initiatives (CRII and CRII+), and deployed the General Escape Clause of the Stability and Growth Pact and the temporary framework for state aid to allow Member States to step in at scale: in 2020, national measures amounted to €3 trillion in fiscal and liquidity support. This was backed up with action by the European Central Bank to support financial stability. -Second, a repair phase used solidarity through the mobilisation of EU instruments amounting to €540 billion to cushion the economic impact of the crisis, including through temporary support to mitigate unemployment risks (SURE). -Finally, we are now in the recovery phase, with NextGenerationEU bringing €750 billion, notably in support through the Recovery and Resilience Facility (RRF) and REACT-EU to support investment and reform over the next six years. Three main characteristics of the policy response: -Speed: the Commission took all decisions in record time, while maintaining proper democratic scrutiny. The CRII entered into force just one month after being proposed. The new €100 billion European instrument for temporary Support to mitigate Unemployment Risks in an Emergency (SURE) was also adopted within a month of being proposed and became operational in summer 2020. The political agreement by the European Council on NextGenerationEU was achieved less than two months after the Commission proposal, and the Own Resources Decision was fully ratified only five months after the start of the corresponding MFF. As a comparison, the last three Own Resources Decisions entered into force after more than two years after the start of the corresponding MFF; -Ambition: the EU economic response united different viewpoints. NextGenerationEU was set up as a temporary and extraordinary measure to address an extraordinary crisis that affected all. This shows that the EU has the capacity to rise to the challenge. -Coherence: the EU economic response delivered supportive and mutually-reinforcing fiscal and monetary policies. Importantly, it also struck a balance between short-term response and longer term imperatives. The Commission pre-crisis agenda-setting priorities were built in to recovery and the design of NextGenerationEU, notably drawing on the European Green Deal, the digital transition and the social element of the recovery. Three lessons learnt for future health response: -The decisive role of EU coordination: Coordinated national fiscal policy responses and the strong role for the EU budget and the Recovery and Resilience Plans will help offset the asymmetric impact of the crisis and allow the EU to grow together. This common EU action on the economy mirrored the essential role of common EU action in areas such as vaccines, but could draw on the experiences and arrangements built to address previous challenges in the economic and financial area and did not need to be improvised. -Resilience of the EU policy coordination system: strengthening the resilience of national economies, the Single Market and the EU’s industrial ecosystems is a key element of the policy response. The response to previous economic and financial crisis allowed the EU to be much more ready to respond to the economic fallout, with tools in place such as the General Escape Clause or the Banking Union. EU health policy did not have such tools already in place to be triggered at moments of crisis. -EU role on the global stage: the weight of the EU economy and the Euro have been key to increase EU resilience to shocks, including the economic crisis triggered by the pandemic. The strong interdependence between EU economies and the rest of the world has also been underlined once again, with global supply chains recognised as never before. Global cooperation in health needs to use the same combination of multilateral commitment and the EU’s global weight to leverage the best health response in a crisis through a continued Team Europe approach. We must now learn from this example, turning emergency action into structural change for a coordinated response to future health crises of this nature. We must take what we have learned over the past eighteen months and turn it into a more systematic approach, a coordinated system that allows for earlier anticipation and detection of risk, better contingency planning, and swifter and more effective joint response. This Communication therefore focuses on health preparedness and response. It starts by providing an overview of the story so far, before drawing ten early lessons from the health crisis where the EU needs to act. It will feed the Leaders’ discussion at the June European Council, be presented to the European Parliament and will be followed up by the Commission in the second half of 2021 with concrete deliverables. 2.LEARNING BY DOING – THE STORY SO FAR By the time the World Health Organization declared a global pandemic on 11 March 2020, the virus had taken hold in Europe. This was exacerbated by the lack – or suppression – of information being shared by the Chinese authorities at the outset of the outbreak. Lacking a robust EU system to declare an emergency situation and trigger the coordination required, governments were already trying to catch up with the reality, and it proved difficult to bring together a consistent and effective early response. There was a clear shortfall in pandemic preparedness and planning, with few tools already in place to respond swiftly and effectively as soon as the pandemic broke out. This was true at global, European, national and local level but was perhaps more acutely felt in Europe, where we had not been tested by the epidemics or outbreaks seen in other parts of the world in recent decades. Attempts to contain the spread of the virus by using internal border closures and checks were uncoordinated and had a limited or counterproductive effect, weakening vital supply chains, while temporary export bans on essential supplies only led to more shortages. In addition, on a global level, trade flows of critical products and materials were hampered by export restrictions and the prioritisation of domestic production by countries outside the EU. In the initial phase, it immediately became clear that healthcare systems were stretched to the limit and the first wave revealed the limitations in Member State health systems in terms of healthcare personnel, the lack of sufficient hospital beds, medical equipment, supplies, and medicines, leaving healthcare workers overwhelmed and the whole system under immense stress. Attempts to mitigate these gaps through increased solidarity in intensive care or medical supplies showed the need and the value of coordination between Member States, for instance by deploying teams and resources to help areas under greatest pressure. However, these efforts were often hampered by a lack of reliable or comparable data. As the crisis continued to unfold, the EU proved itself capable of responding effectively across the board. It increasingly shifted from unilateral actions towards convergence of decisions and developed a wide range of policy responses, adjusting and updating to the different phases of the pandemic. This is exemplified by the common approach to vaccines but is also true of new initiatives across a range of other policies. The Green Lanes initiative maintained the integrity of supply chains, ensuring supplies of food and medicines in the Single Market, and the common approach to assessing infection rates in different regions helped bring more consistency to imposing testing and quarantine. Tax and Customs initiatives were swiftly taken to help the supply of vital medical and protective equipment and Guidelines supported the safe movement of frontier and seasonal workers across borders. EU rules on cohesion policy were amended with an unprecedented speed, allowing Member States to rapidly redirect EU funds to finance emergency needs in the healthcare sector.

More recently, the Commission proposal for an EU Digital COVID Certificate was agreed and implemented in record time, paving the way for the lifting of free movement restrictions, and the resumption of tourism and travel. This initiative also showed the value of improving cross-border interoperability of information systems and data flows. A key area of response to assess is the approach taken to developing, procuring and producing vaccines. Learning from the initial disjointed response to the crisis, the Commission presented in June 2020 a common EU Vaccines Strategy. This enabled the support and speeding up of development and manufacturing at scale. Negotiations with vaccine producers have sometimes been challenging, but the approach has ensured access to COVID-19 vaccines for all Member States on the scale allowing the rollout we see today, as well as exports to more than one hundred countries worldwide. All 27 Member States agreed to join forces and give the Commission the mandate to carry out tasks that were traditionally considered to be national decisions. This was an essential step to overcoming the pandemic together and had it not been in place, Member States would have been competing with each other for fewer doses from fewer producers. We would have seen significant variations in speed of vaccination and would have faced a higher risk of inequity, variants and travel disruption. Instead, as it stands, over half of European adults have received one dose while over a quarter are fully vaccinated. Whilst more remains to be done, this is a historic common achievement in record time and enables the gradual, sustained and safe reopening of social and economic life and the support to our international partners. At the same time, this success does not mask the difficulties that were encountered, notably scaling up manufacturing and production capacity, and dependencies on global supply chains. This was partly down to the lack of a permanent integrated approach to research, development, market authorisation, production and supply. While this has since been addressed in the context of COVID-19 vaccines, a longer term solution is needed for future health events or crises. 3. THE TEN LESSONS OF COVID-19 FOR PUBLIC HEALTH POLICY Learning lessons from any crisis starts with an honest reflection of the past and the present in order to improve for the future. In this spirit, each of the ten lessons drawn in this report focuses on what needed to be improved and what can be done better in the future. The ten lessons are not exhaustive or mutually exclusive – they simply provide a first snapshot of what we already know can be done to secure a more effective health response. Lesson One: Faster detection and response depends on stronger global surveillance and more comparable and complete data As with every outbreak of a new infectious disease, early detection is essential for successfully containing the spread of a disease and its impact on people, economies and societies both locally and globally. Surveillance systems across Europe and the world enable faster detection and earlier notification to others, as well as a much more informed management of a pandemic under way. They also allow experts from across the world to carry out research and risk analyses on new viruses and on their potential impact or threat. COVID-19 highlighted the essential role of these surveillance systems, which successfully picked up reports of concerning clusters of pneumonia cases as early as 31 December 2019. Once the genomic sequence was released in mid-January, this enabled the development work on tests, treatments and even vaccines to begin in earnest. However, the pandemic also showed the limitations of the current surveillance systems. They revealed that they are only as effective as the data that feeds them. In the initial weeks after the first case, a lack of comparable and complete data meant that much of the threat assessments and scientific research could not be carried out to the fullest extent. Critical time was lost in detecting the true scale, speed and severity of the epidemic, leading to delays in key decisions across Europe and elsewhere. As a result, global coordination took too long to be put in place. As the International Panel for Pandemic Preparedness and Response concluded, the current international alert system “does not operate with sufficient speed when faced with a fast-moving respiratory pathogen.” This is why a new global surveillance system needs to be put into place, with the necessary tools and open environment to share data at the earliest possible stage. This should focus on greater coverage of surveillance networks in parts of the world where there are gaps, as well as facilitate faster exchange of comparable data. At European level, a new European pandemic information gathering system, building on the existing Early Warning and Response System and an upgrade of the European Surveillance System, should be set up to manage and exchange data in real time and integrated into the new global system. This should focus on Member States providing timely information, ranging from early signals of potential threats – whether pandemics, bioterrorism or anything in between – to concrete data on cases, exposures, risk factors, health outcomes and healthcare capacity. As part of this, connecting public health authorities would allow coordinated management of stockpiles and hospital beds, and rapid workforce redeployments. It would allow up-to-date screening of the situation to be shared, drawing on innovative sources of data like the wastewater monitoring now being put in place. It will also allow swifter and more effective contact tracing, as well as enable patient records and data to follow patients across borders. This should also be integrated into the broader initiative to create a European Health Data Space. Seamlessly linking clinical and public health data, such as through the secure sharing of electronic health records, allows a real-time snapshot of the epidemiological situation and response capacity. Drawing the lesson: -The EU should lead efforts to design and implement a new, robust global surveillance system based on comparable and complete data. -New and improved European pandemic information gathering system to be launched in 2021 Lesson Two: Clear and coordinated scientific advice facilitates policy decisions and public communication While policy making and public messaging during the COVID-19 pandemic continue to be informed by the latest scientific advice, the early months of the crisis exposed the uneven level of research and advice in different Member States, as well as the different approaches taken to providing and using that advice. This meant that evidence was patchy, sometimes contradictory and often confusing as a result of different messaging in different Member States. The need to share knowledge and expertise and align messaging and advice prompted the European Commission to set up an advisory panel on COVID-19 composed of epidemiologists and virologists from different Member States. This panel continues to inform EU guidelines on science-based and coordinated risk management measures. Other new groups, such as the EU Scientific Advice platform on COVID-19, have provided a forum for peer exchange and coordination among scientific advisors to national governments, and have complemented work of the European Centre for Disease Prevention and Control (ECDC). The success of these groups does not hide the need for more coordination at EU level on scientific advice and for consistent, coherent and factual communication. There is a need to bridge the gap between science and policy-making, and for an authoritative EU scientific voice to communicate directly to the public, as was successfully done in countries in Europe and across the world. To address this, a new European Chief Epidemiologist would help bring together leading epidemiologists in Member States to formulate evidence-based policy recommendations to the Commission and act as a point of communication with the public in times of crisis.

Drawing the lesson: -The EU should appoint a European Chief Epidemiologist and set up a corresponding governance structure, by the end of 2021. Lesson Three: Preparedness needs constant investment, scrutiny and review If there is an overarching lesson for Europe to heed, it is that preparedness and planning was not as robust, financed or as comprehensive as it needed to be. While there were many preparedness plans, the systems and infrastructure to update these and put them into motion did not always match the requirements needed. As in many other parts of the world, a historic and systemic underfunding in preparedness significantly hampered the first response efforts in many parts of Europe. As this crisis has shown, the cost of non-action far strips the cost of effective and systematic investment in preparedness and planning, including strategic foresight. A new, systemic approach to preparedness is needed to learn the lesson from this pandemic. This starts with stepping up investment, for instance with an earmarked preparedness budgets to support initiatives such as stockpiles at national and EU level. Regular reviews and audits should be undertaken to ensure that the latest threats, trends and risks are addressed and capacities are in place should preparedness plans need to be put in motion. To support this, the Commission will prepare an annual State of Preparedness Report to reflect the overall changing risk landscape in Europe and the state of preparedness. It will cover pandemics and other health emergencies, along with other scenarios that the EU may realistically have to face in the near future. These include chemical, biological, radiological and nuclear attacks or accidents, large seismic shocks, environmental or technological disasters, or a widespread blackout. In preparing the report, the Commission will draw on all relevant expertise and authorities in these fields. Drawing the lesson: -The European Commission to prepare an annual State of Preparedness Report to be presented to the European Council and European Parliament. Lesson Four: Emergency tools need to be ready, faster and easier to activate A striking feature of the pandemic was the increasing use of different emergency tools needed in response to the crisis. These include the use of the Emergency Support Instrument, the Advance Purchase Agreements used to purchase vaccines, or the use of the Union Civil Protection Mechanism for emergency response and repatriations. While these instruments were successfully deployed, the pandemic highlighted the importance to have fast, functioning and flexible temporary and exceptional measures ready to be activated, to allow the EU to react as quickly as it is needed. With speed being of the essence, the pandemic showed the need for a more systematic approach to these instruments. This requires a clear and decisive political decision on when to trigger crisis response, as well as a toolbox to be deployed for such situations. This could include the automatic activation of the Emergency Support Instrument to allow surge funding, or other mechanisms to allow swift support for the research, development, manufacturing and procurement of essential countermeasures. It could also ensure a more coordinated approach to information-sharing and decision-making on public health measures. The toolbox should include targeted measures covering specific sectors. A proposal will be made in 2022 for a Single Market Emergency Instrument (SMEI) to provide a swift and flexible response to the impact of any given crisis on the Single Market. It would include triggering the possibility under public procurement legislation to fast-track negotiations in cases of extreme urgency, as well as allowing for procurement on behalf of Member States for goods beyond the current limitation to medical counter-measures. In line with the Strategy towards a fully functioning and resilient Schengen Area, the Commission will propose initiatives to put in place a stable framework for EU coordination of internal and external border control measures, as well as a contingency plan for transport and mobility to build on the experience of the successful Green Lanes framework so that measures can be put in place if required for the exceptional circumstance of temporary internal border measures blocking traffic. Drawing the lesson: -Establish a framework for the activation of an EU Pandemic State of Emergency and a toolbox for crisis situations Lesson Five: Coordinated measures should become a reflex for Europe Many of the initial responses to the COVID-19 pandemic were characterised by unilateral decisions and a lack of coordination. This led to widely varying and unilateral approaches to the health interventions between Member States. Restrictions designed to contain the virus were also changed very frequently, and there was considerable variety in testing policies and methodologies. The result was to undermine public trust and compliance with the measures in place, and to reduce their effectiveness. Although the focus of Member States was on unilateral measures during the early days of the COVID-19 outbreak in Europe, there was a gradual move towards greater solidarity and cooperation as the limits of purely national approaches became clear. However, it is clear that the coordination was too slow and too ineffective, in part down to information and expertise being scattered across various inter-institutional working groups. There is a clear need to further strengthen inter-institutional cooperation, streamline decision-making and better combine the necessary expertise with sufficient authority to ensure timely and informed decisions during a crisis. Designating the main group or entity in each institution to be activated during a crisis and establishing efficient working methods between them could help ensure strong inter-institutional coordination. This needs to be backed up with clear political support from the Heads of State and Government in the European Council. As a first step to improve the coordination of public health measures across the EU, the European Commission made a set of proposals on building a European Health Union in November 2020. These proposals will revamp the legal framework for dealing with cross-border health threats, and strengthen the crisis response mandates for the European Centre for Disease Prevention and Control (ECDC) and the European Medicines Agency (EMA).Data reporting and surveillance would be strengthened. There will be regular reporting on and auditing of EU and national preparedness plans. ECDC’s capacities to support Member States in preparedness and response will be enhanced, and EMA will have a stronger role in monitoring and mitigating shortages. Drawing the lessons: -Strengthen coordination and working methods between each institution’s main contact group or entity to be activated during a crisis. The European Health Union legislative package should be adopted swiftly - before the end of the year Lesson Six: Reinforced public-private partnerships and stronger supply chains are needed for critical equipment and medicines The pandemic has highlighted the need to increase resilience of supply chains important for the security of many critical supplies. In the area of health, it created a surge in demand for key products such as medicines, ventilators, and masks. Global supply chains came under huge pressure. Competition for products led to shortfalls and inequalities, while creating a major obstacle to planning an effective response as the virus took hold. As a result, in the early months of the pandemic, Europe suffered from shortages of tests and testing material, trained personnel and, in some cases, supplies of laboratory equipment. In addition, the global ramp-up of vaccine production resulted in bottlenecks of key production materials and ingredients. This revealed a number of over dependencies, as well as the fragility of global production processes, especially in medical goods and pharmaceuticals.

The EU used a series of measures to address these vulnerabilities, from joint procurements of personal protective equipment to stockpiles of ventilators and masks. A ‘Clearing house’ for medical equipment helped match supplies to national demand and a monitoring system was launched to anticipate drug shortages. A Task Force on industrial scale-up was established to resolve supply chain bottlenecks and foster industrial partnerships. A temporary export authorisation mechanism provided transparency on vaccine trade flows, while keeping supply chains open and retaining Europe’s role as the world leader in vaccine exports. Such ad hoc measures increased access for Europeans to essential supplies and made the most of the EU’s possibility to work at scale. However, they also revealed the huge knowledge gap at the start of pandemic in terms of manufacturing capacities and potential Member State demand, as well as the depth of reliance on global supply chains. This points to the need to be able to monitor and shape market priorities and capacities for essential health supplies at every stage, from research and development to production and supply. To support this, a new Health Emergency Preparedness and Response Authority (HERA) is essential to ensure better EU preparedness and response in terms of medical countermeasures to serious cross border health threats. This would boost market intelligence and foresight. It would also strengthen development, production and distribution capacities in the EU – integrated with national efforts and the private sector – supported by flexible financing and procurement tools. By pooling existing capacities to increase scalability in the EU, it would ultimately enable Member States to access vaccines and therapeutics earlier and at greater scale. HERA’s work would also have a strong international dimension, working with other partners and regions. At the heart of this approach, and learning from the crisis response, is the need to combine public and private efforts to incentivise breakthrough research and innovation in the health and pharmaceutical sector, making it more resilient. This can, for instance, be done through an Important Project of Common European Interest (IPCEI) focused on developing new generations of pharmaceutical products or breakthrough manufacturing technologies. The Commission stands ready to support Member State and industry plans for a possible IPCEI in pharmaceuticals and coordinate where necessary. The crisis also showed the need to improve our knowledge of manufacturing capabilities that could be available in a public health crisis. To address this, the Commission will develop an interactive mapping platform to support the analysis of the supply chains and any possible bottlenecks. A pilot will be launched this year under the EU4Health Programme. The EU should use this information to address supply chain vulnerabilities and dependencies, and to boost manufacturing capacity for key ingredients and materials for the production of vaccines and therapeutics to address the health crises. A call for expression of interest for the EU FAB facility will be launched, aiming to ensure that the EU has enough “ever-warm” capacity to produce 500–700m doses vaccine doses per year, with half of these doses to be ready in the first six months of a pandemic. Drawing the lesson: -A Health Emergency Preparedness and Response Authority (HERA) should be operational by early 2022. - Set up a Health Important Project of Common European Interest as soon as possible to enable breakthrough innovation in the health and pharmaceutical sector, making it more resilient. Lesson Seven: A pan-European approach is essential to make clinical research faster, broader and more effective As the pandemic continues, it is of vital importance that Member States do everything they can to expedite rapid approval of clinical trials of vaccines and therapeutics. A fragmented and divided approach to clinical trials across Europe since the beginning of the pandemic has hampered efforts to track and analyse variants. This was exacerbated with the lack of sequencing and testing capacity in most Member States at various stages of the pandemic. With the risk of variants posing the most serious challenge to reaching the end of the pandemic in Europe, the need for larger and more coordinated clinical trials has become all the more acute in the short to medium term. To boost these capacities and support open data sharing and cohorts studies, the Commission supported a new EU-wide vaccine and therapeutics trial network called VACCELERATE, using Horizon 2020 funding. The permanent establishment of a large scale, flexible, well-resourced platform for multi-centre trials would help establish a structured approach to EU clinical trials for future crises. This strengthened support and simplification of clinical trials could, for instance, be an important tool in the fight against cancer or other diseases. Beyond clinical trials, the EU must continue to draw on its powerful research base. Under Horizon 2020, the Infectious Diseases Finance Facility was instrumental in providing finance to very risky, but promising projects by companies developing vaccines, treatments and diagnostic technologies for COVID-19. Its budget of €400 million included support to the vaccine candidates of BioNTech and CureVac. However, the structure of the EU’s research instruments meant that such support was not linked to future procurement by the EU or the Member States. In the future, a more joined up and flexible approach under the new HERA will help ensure that critical research investments are better linked to procurement. Drawing the lesson: -Establish a large scale EU platform for multi-centre clinical trials Lesson Eight: Capacity to cope in a pandemic depends on continuous and increased investment in health systems The pandemic exposed structural weakness in health systems. While different Member States faced different challenges, there were a number of common challenges. These included the lack of surge capacity, the speed at which health systems became fully operational and the significant spillover impact it had on tackling other diseases or providing other health services. The fact that health systems were able to help so many people was down to the dedication, sacrifice and leadership of so many health workers across the EU. While this is testament to the professionals involved, it does not hide the fact that health systems in Europe need to become more resilient and that healthcare services and public health prevention and preparedness efforts need to be better integrated. This starts with ensuring that investment in the capacity and effectiveness of health systems, including investment in better working conditions and attractiveness of the health and care professions, is stepped up. EU4Health, the cohesion policy funds, and the Recovery and Resilience Facility all provide key funding opportunities to boost investment in public health functions and capacities. The Commission welcomes that Member States have proposed a wide range of health reforms and investments in their Recovery and Resilience Plans to strengthen resilience, quality, accessibility and efficiency. This includes a focus on investments contributing to the digital transition, in infrastructure, skills and shifting healthcare delivery to telemedicine. To support this, the European Semester process can also support regular assessment of national health system resilience, and EU cohesion funds can support structural changes and capacity improvements. Drawing the lesson: - Member States to be supported to strengthen the overall resilience of health care systems as part of their recovery and resilience investments. Lesson Nine: Pandemic preparedness and response is a global priority for Europe The evolution of the pandemic has made clear that only a global response can provide a long-term answer to the virus. Even as Europe reaches its vaccination goals, and some Member States start to inoculate children, other parts of the world do not have access to the vaccines they need. This increases the risk of the pandemic spreading further and of new, potentially vaccine-resistant variants developing and circulating in Europe. This is a matter of solidarity and of self-interest. These lessons apply to any global pandemic and requires mobilising policy, financial and diplomatic instruments. From the beginning, the EU and its Member States worked together. This included joint efforts to repatriate EU citizens stranded overseas. It also meant coordinated efforts via the ‘Team Europe’ approach to lead international solidarity, and mobilise financial instruments in a flexible way. This approach enabled the EU to be at the forefront of the international efforts to curb the pandemic. The EU worked to establish and support the tools to share vaccines with lower and middle income countries, the ACT-Accelerator and COVAX. Team Europe remains one of the biggest supporters of COVAX, having committed close to €3 billion, including €1.3 billion from the EU budget in funding and the EU has pledged to donate 100 million doses of vaccines before the end of the year. It has also offered humanitarian assistance and helped bring medical supplies to people in hard-to-reach areas. The EU has also led the way in keeping supply chains and trade open, with around half of the vaccine doses produced in the EU being exported. However, other parts of the world chose a more narrow and closed approach, with the blocking of exports from a number of countries leading to serious delays in the production of vaccines at the global level. The EU should respond be ready to respond quicker to such actions but will always remain determined to cooperate internationally. In this spirit, the EU is advocating multilateral action in the World Trade Organization to maintain open supply chains and reduce barriers to trade, as well as taking a holistic approach to the problem of equitable vaccine distribution, including on the intellectual property. Our neighbourhood also requires particular attention. Cross-border activity has been particularly hit by uneven access to vaccines and medical equipment. Partners in our immediate neighbourhood should be brought into EU efforts to increase preparedness and responsiveness, including the future HERA, while also continuing to receive support in capacity building, monitoring, training and structural adaptations of infrastructures.