Gaining health : analysis of policy development in European ...

Chapter 4
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on public health represent around 20% of the curriculum.
Basically, ENSP aims at tutoring specialized bureaucrats to
ensure expertise in public health in national or regional
government bodies. There are other universities in “specialized
public administration” (such as the National Education
Centre for Field Workers) that train public administrators
of regional and local authorities and include public health
courses.
From the very beginning, ENSP was devoted to education
in public health and management. Students of the school
are heads of administrations, state employees and doctors
employed in health and social work. This has not changed
in the last five decades, but the Public Health Act of 2004
expressed a need for some modernization by giving the
school more status in the education system. In 2004, the
school became a postgraduate university-style institution.
Nevertheless, the dominant approach in the curriculum
did not change and it continues to be designed for hospital
directors, health inspectors, and school doctors and nurses.
The programme is a one-year sandwich course with both
theoretical and practical aspects.
Experts consulted stated unanimously that schools that
were not purely administrative in approach were needed in
the field of public health. Nevertheless, there is no consensus
as to whether ENSP could fill this role. As a striking
indicator of the dearth of public health training in France,
it is often mentioned that Belgium (one fifth the size of
France) has more public health schools and health promotion
research.
4. Forces facilitating or obstructing disease
prevention
France has many national NCD-related programmes but
they exist in parallel, lacking a comprehensive, coordinative
umbrella strategy. Owing to the strong advocacy of
specific interest groups, reforms and new programmes and
strategies have been tacked onto existing ones without
replacing them. This has led to an extraordinary complexity
and compartmentalization within the system. To reduce
this element of redundancy and parallelism, an attempt was
made in the Public Health Act of 2004 to provide a framework
for different public health policy areas. The Act being
basically “only” a legal framework, however, it was unable
to replace existing programmes and after 2004 even more
new programmes were launched.
The distribution of power is complex and lacks full transparency.
The process of decentralization failed to abolish the
deeply rooted vertical hierarchy; in fact, it added horizontal
structures and brought in external players. While the
Government provides guidance through national strategies
that should be implemented at regional and local levels, the
regions are also expected to develop their own regional
health plans. This distribution of competencies has led to
increased overlaps and complexity. On the other hand,
bodies at regional and local levels apply the concept of
subsidiarity, enabling an adequate response to specific local
needs and contributing to reducing health inequalities
among regions.
The strong advocacy and long-term experience of NGOs
substantially facilitate NCD policy development in France.
NGOs not only supplement the activities of government
but, owing to their having top experts among their members,
help formulate and implement health policies in the
public sector. There are NCD policy areas such as cancer
and nutrition that are historically “lobbied” by influential
associations representing powerful views in French public
health policy. For instance, cancer research and prevention
are widely institutionalized and multisectorally represented.
Objectives of the cancer plan cover a wide range of risk
factors and determinants of health such as smoking, alcohol
use and nutrition. PNNS also includes a broad range of risk
factors and health determinants.
Case studies: policy development in countries for tackling noncommunicable diseases