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

Chapter 5
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opment needs longer-term planning and has less tangible
short-term results. Where classical public health issues still
prevail, and the general economic and social situation is not
propitious, the time may be not ripe for governments to
give priority to NCD policy development.
The policy environment
In a number of countries, a more general change in the
policy environment converged with a recognition of the
problem of NCD when the state’s responsibility for health
(and not just for health care) was clarified. This was reinforced
in some cases through constitutional changes or
public health legislation and presented an opportunity for
bringing NCD higher on the policy agenda.
When Lithuania regained its independence, the political
mood and urge to redefine the national identity, together
with the re-establishment of the Medical Association,
offered an opportunity for a radical rethinking of the approach
to health policy. A number of countries used their
entry to the European Community and/or their presidency
of the EU to bring NCD issues to the fore. For example,
the French presidency of the EU was an important trigger
in shaping a new policy on nutrition and physical activity in
France, offering political success and recognition.
A special dilemma is the lack of an explicit NCD policy or a
lack of decision-making. In the WHO European Region, the
explanation of such a phenomenon is usually not policymakers’
lack of awareness of the issues. There are various
reasons for a failure to promote NCD policy, including:
• the lack of short-term political gain;
• concern regarding the feasibility of changing lifestyles;
• the fear of negative public reaction;
• the lack of a “window of opportunity”; and
• the fact that many countries are fully occupied with the
problems of health care financing, providing accessible
and good-quality care, reducing waiting lists and meeting
demands for new types of care.
Key actors in the awareness-building process
As clearly indicated by the case studies, key individuals,
advocacy groups and public opinion can play an important
role in awareness building.
Politicians
New presidents, prime ministers and ministers of health
may be powerful agenda-setters, since the newness of their
position allows them room for manoeuvre and new initiatives.
In Hungary at the beginning of the 1980s, for instance,
a new Deputy Prime Minister, with a medical background
and inspired by the WHO Health for All policy, initiated
the process for developing a long-term health promotion
strategy by positioning herself politically in favour of intersectoral
action. Four successive governments in Hungary
developed new health policies under different labels,
each attempting to create symbolic differences and a new
identity compared to their predecessors. In Kyrgyzstan, the
public health strategy Manas Taalimi can be clearly related
to a change in government, a new Minister of Health and a
Deputy Minister responsible for public health.
Individual advocates or prime movers
In all the study countries, certain prime movers played an
outstanding role in initiating the NCD policy development
process. The first generation of prime movers, a product
of the late 1970s and 1980s, were deeply involved in the
first national/international cardiovascular projects and the
WHO Health for All movement and were pioneers in the
Ottawa Charter. These people combined a number of skills:
a very high level of expertise, an open mind, political and
managerial ability, and a cooperative spirit. The role of such
outstanding personalities is clearly demonstrated in the
case of policy development in Finland, Hungary, Ireland and
Lithuania.
Reflections on experiences