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

Chapter 5
224
surveys over long periods of time and offering comparable
international data and training or nurturing national teams
of experts. In Hungary, most of the outstanding prime movers
behind the policy documents in the 1980s and 1990s
had previously been directly involved in the MONICA
Project.
In countries with a long history of NCD policy development,
work carried out in relation to monitoring and
revising previous policies provided a significant source of
information for new policy formulation, saving time and energy.
In Finland, Ireland and Lithuania in particular, extensive
evaluations of previous policy implementation add to the
rich source of information utilized, and are probably conducive
to identifying potential difficulties in policy implementation.
Reflecting inequalities in health
The availability and use of data on socioeconomic differences
in mortality, morbidity and lifestyles are well-developed
in some case-study countries and sporadic or completely
missing in others. In Finland, Ireland and Lithuania, epidemiological
data on mortality and morbidity reflecting inequalities
in health are available to a reasonable extent, not only
at national but also at regional and local levels. In these
countries, such information is published in regular reports
and can be readily utilized in formulating health policy. Such
reports can also give decision-makers a better understanding
of the need for intersectoral action and for shifting the
focus of attention to tackling the determinants of health.
High-quality research, if easily available, may be picked up
when the time is ripe, such as in England where the famous
Black Report (4) on inequalities in health was first published
in 1980. Although frostily received by the government of
the day, this and similar reports proved to be a valuable and
ready-made resource to be utilized when the political mood
offered a window of opportunity. The Netherlands carried
out extensive research programmes involving research
institutions across the country for over a decade, first to
explain inequalities in health and second to generate more
knowledge on the effectiveness of interventions and policies
to reduce socioeconomic inequalities in health (5).
The “mapping” of inequalities has also proved to be a powerful
tool at the local level, such as in Finland and Lithuania
where it raises awareness among politicians, who compare
“their” region to their neighbours’. A number of other
countries outside the study group offer excellent examples
of the effective use of mapping for policy development.
Pioneers such as the City of Rotterdam, for example, have
developed indicators and software programs not only to
signal public health problems but to try to identify determinants
and offer solutions on a policy level (6).
Socioeconomic determinants of health
Information on the socioeconomic determinants of health
are much less prevalent in the policy formulation process,
except in those few countries where equality in health is
more than a rhetorical factor in policy formulation. The
Swedish public health policy is a notable exception.
Owing to the activities of the WHO Commission on Social
Determinants of Health, important progress has been made
in strengthening the scientific knowledge base for policy development.
This conceptual framework was not available for
the NCD policy planning processes examined here, but may
strongly influence health policy development in the future.
Availability of health care for NCD
Perhaps surprisingly, information on the availability, accessibility
and effectiveness of health care for NCD does not
appear to be generally available. Studies led by the EU have
uncovered considerable and unacceptable inequalities in this
area. An attempt in Ireland to explore this situation recently
led to the development of a framework for managing care
for chronic diseases.
Reflections on experiences