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

Chapter 4
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The Public Health Programme for a Healthy Nation elaborated
by the Conservative Government in 2001 served as a
kind of template for the further development of the NPHP.
A situation analysis was more or less available, based on
detailed epidemiological data including geographical and
social differences in mortality, morbidity and risk factors.
There was little discussion of the basic values inspired by
key WHO and EU documents. The insufficiencies and conflicts
in the strategic planning were related to the lack of a
clear planning system, process and practical coordination. In
fact, a formal priority-setting mechanism was missing, with
the result that the process was unduly influenced by lobby
groups.
The NPHP therefore became a sort of melting pot with 19
priority directions, very much based on the 17 activity areas
of the previous programme of the Conservative Government.
In the climate of sharp political debate in Parliament,
the NPHP offered a unique opportunity for consensus
building. This was a decisive factor in government policymakers
emphasizing the continuity and similarities with the
former document.
The 19 priority areas included some traditional public
health activities linked to the EU accession process and created
a delicate balance among the different interest groups,
trying to avoid conflict and please everyone. Working
groups were established to develop the details of each priority
area based on a common template and to produce a
two-year work plan of implementation. The working groups
were given around three months for the drafting process.
This short time precluded opportunity for substantial
consultation and, the involvement of important stakeholders,
and resulted in limited coordination and harmonization
among the 19 areas.
The general introductory part of the NPHP – including the
visions, goals, basic values and approaches – was drafted
after the 19 working groups had finished their work. This
contributed to the lack of full consistency between the basic
principles and the real work plans. The general introductory
part was inspired by basic international documents but
the proposals of most of the working groups were more
traditional, with a medicalized and individual risk approach.
In technical terms, the strategy document offered great
freedom in terms of implementation, without demanding
annual priority-setting, but also making the whole process
fragile and dependent on the changing political commitments
of the various actors.
The text of the NPHP did not include a description of the
way in which it should be implemented. In fact, the NPHP
was basically characterized by a top-down approach to
implementation. Because of the uncertainty related to the
rapid changes in health care reform, the central managerial
and coordinating structure is fluid and unclear.
The NPHP was provided with considerable resources compared
to previous programmes. The work began in many
areas at once, creating capacity problems at local level and
coordination difficulties at central (governmental) level. The
NPHP did not focus on key development areas, too many
fields of activity were incorporated into the implementation
plan and priorities were not set, mainly due to political
decisions and lobbying independent of the technical and
feasibility considerations.
The initial budget was subsequently halved because of
general budgetary restrictions, and the administrative and
institutional capacity for implementation deteriorated. The
financial support at the beginning of the programme was
quite robust, but in later years it was insufficient to complete
newly begun elements of the programme. The lack of
adequate research and human capacities has been a permanent
problem in programme implementation. Capacity
building needs systematic development. Financial cutbacks
affected these areas immediately, leading to further deterio-
Case studies: policy development in countries for tackling noncommunicable diseases