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Background The European Semester (ES) is a policy coordination and scrutiny framework at EU-level for surveillance of fiscal and macro-economic policies in Member States. Health systems have not evaded that scrutiny. The analysis focusses on how health systems reforms are being endorsed in Country Specific Recommendations (CSRs) and how the ES process links to planning and implementation of national health system reforms over the period 2015-2018. Methods A descriptive content analysis of CSRs with a search for the keywords and phrases ‘health’, OR ‘healthcare’, OR ‘long-term care’ was performed for the years 2015-2018. Furthermore, CSRs addressing health systems were classified according to whether they were targeting access, quality or sustainability; and categorized regarding organisation and governance, financing, physical and human resources, and provision of services. Finally, implementation progress on the health CSRs was rated according to EC’s own evaluation scheme derived from the preceding year’s country report. Results CSRs with health system recommendations have featured continuously in the ES process each year and have stabilised in number. The themes of health CSRs are still dominated by financial sustainability, cost-effectiveness and of financing, although other health system goals and domains, particularly access, are increasingly addressed. There is a high degree of consistency on the content of health CSRs over the years for each country addressed. Progress with implementation of health CSRs is disappointing so far, based on the EC evaluations. No clear link between discontinuation of health CSRs and evidence of progress in implementing the CSR can be discerned. Conclusions The results uncovered some of the links between national and European institutions leveraging the ES to push health system reforms. However, a more balanced and long-term view is needed for the ES to contribute solidly to complementing national efforts in a complex reform context. Key messages Health CSRs are still dominated by financial sustainability considerations while other health system goals and domains are increasingly addressed. Progress with implementation of health CSRs is disappointing so far, although a longer-term perspective is needed to pay tribute to the complex reform environment of health system reforms.

The European Semester 2015-2018: themes and progress of country specific recommendations on health