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

Chapter 2
History and context of policies
to tackle NCD
Péter Makara & Jill L. Farrington
The historical origins and the period of
pilot projects
Before analysing policies for tackling NCD that exist in
Europe today, we would do well to look to the past for
guidance and a better understanding of their origins. The
historical development of the NCD policy process was
initiated by basic changes in health status in Europe and
the new prevailing role of NCD in morbidity and mortality
statistics. A new epidemiological era started, bringing with it
challenging new public health approaches.
After the identification in the 1950s of tobacco smoking as
the principal cause of lung cancer, other major risk factors
for NCD became known, mainly in the 1960s and the early
1970s. The evidence that epidemiologists generated on the
role of risk factors influencing health problems and their
magnitude was impressive. The results of experimental
and observational studies in the 1970s, guided partly by
WHO, led to evidence-based preventive interventions and
increased the direct impact of epidemiology on policy decisions.
The first pilot projects, such as that in North Karelia
(1) and Heartbeat Wales are still pioneering examples of
good practice and are referenced in most policy documents
on NCD prevention.
The combination of developments in epidemiology, the
American approach to setting national health objectives
(1980) (2) and the Lalonde “health field” concept (1974)
(3), which emphasized the interaction between lifestyle
and environment, human biology and the health services,
contributed to new approaches in health policy thinking.
This shift began to occur around an important WHO global
meeting at Almaty (then Alma-Ata) in 1978. The Declaration
of Alma-Ata (4) formally promoted primary health care
(PHC) as the most important mechanism for health care
delivery. The Declaration recognized that health improvement
should not occur just by developing more health
services or by imposing public health solutions in a topdown
way. It called for a shift in power from the providers
of health services to the consumers of those services
and the wider community. This way of thinking stimulated
WHO in 1981 to prepare a Global Strategy for Health for
All with a series of clear objectives. The Regional Office
produced 38 targets for the European Region to complement
the Global Strategy (5). These targets were endorsed
in 1984 and motivated policy-makers to think rationally
about health policy development. The strategy was broadly
used as a tool to improve health policy and the methods
and structures required to bring about significant improvements
in population health. By the early 1990s, most of the
governments in Europe had adopted broad policies of the
Health for All type.
With the use of targets, efforts to monitor and evaluate
consistent activities also increased. More specific epidemiological
data on various problems and population groups
Chapter 2
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History and context of policies to tackle NCD