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

Chapter 4
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groups and the health Ministry). An interesting feature of
French NCD policy development is that some policies were
initiated by the President (within the framework of the
so-called presidential initiative) while others were set up
by Parliament or the Ministry, and these programmes have
different legal status. The Public Health Act of 2004 was
intended to facilitate a broad common policy, but it lacked a
policy concept and its main purpose was only to provide a
legal instrument for the implementation of already existing
public health policies, thus leaving the fragmented structure
of them untouched. Moreover, a clear objective of the Act
was to assist the decentralization of public health programmes
in the country.
5.2. Indications of the value system underlying policy
development
Values and visions are less pronounced and rather more
implicit in NCD-related programmes and documents than
in other countries. Inequality is often emphasized as a basic
problem, but there is a sharp conflict between France’s Gini
index, regional and social inequalities, and the declaration
of values in strategies. Tackling socioeconomic determinants
of inequalities in health does not appear often in policy
language and this is certainly not a strength of French NCD
policy development.
5.3. From awareness building to policy action
The creation of the HCSP was a milestone in NCD policy
development. This advisory body provided a strong voice
and powerful advocacy for public health. The regularly published
reports of the HCSP contributed to better prioritysetting
by focusing on objectives and calling attention to the
major challenges of the French public health system.
This complicated policy development, based on a balance
of different forces, has been sustainable in the last decade.
However, significant changes can be expected in the role
of the regions and in the financing of public services in the
near future.
French health communication is undoubtedly among the
best in Europe.
5.4. Sustaining policy implementation, monitoring
and revision
Comprehensive and reliable health information is provided
by different public institutions on various health issues and
many high-quality studies have been conducted. Public
health institutes carry out data collection and research and
publish their findings on a regular basis. France participated
in the MONICA Project but not in the CINDI programme.
Every five years, INPES issues its Health Barometer with
valuable information on the health behaviour and attitudes
of the population. The Regional Health Observatories provide
epidemiological data about the health of the population
in the regions. In addition, InVS participates in data and
information collection. In terms of NCD policy, the regular
reports and information of INPES and INSERM are crucial
and have a considerable policy implication.
Despite the broad nature and high quality of available health
information, in the light of the lack of a coherent overall
policy implementation mechanism all this data can hardly be
considered as a general monitoring and evaluation system in
NCD policy development.
5.5. Key conclusions
• The integration of French NCD policy is controversial
and difficult to describe in terms of being top-down or
bottom-up.
• There is a government-level umbrella strategy that can
be considered rather as an eclectic framework of existing
activities than as a centrally driven strategic process.
• The French policy includes nearly all the thematic areas
of NCD policy at a high technical level.
• The decision-making system is only theoretically centralized,
the process and financing mechanism being
provided by the interplay of different key actors.
Case studies: policy development in countries for tackling noncommunicable diseases