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

civil servants have a degree of permanence, they are not
necessarily utilized by governments of different political
persuasions.
In central and eastern Europe in general, the post of minister
of health has changed on average every 18 months, and
together with the minister there is frequently a large turnover
of experts. On the contrary, in countries where NCD
policy development has been sustained over a long period
of time, such as Finland, Ireland and Lithuania, a critical
number of civil servants and experts have been called on
in the policy formulation process regardless of changes of
government, bringing with them both a strong institutional
memory and a network of useful contacts. The possible
danger of such long-term stability might be a tendency to
consider that there is only one way of doing things and to
ignore other policy options.
In some countries, the first initiative is taken by expert
structures such as national health councils. Where they exist,
such councils frequently play a strong role in policy formulation,
one advantage being that they have the necessary
expertise and facilities in place. Examples are the National
Board of Health set up in 1998 in Lithuania and the High
Committee on Public Health established in 1991 in France,
which play a decisive role.
In countries such as Hungary, where a National Public Health
and Medical Officer Service is still in place, with a Chief
Public Health Officer and corresponding offices and officials
at county and municipal levels, this top-down structure is
extremely influential. This is characteristic of countries having
a history of experience with the sanepid system.
In general, planning groups or task forces consist of a mix of
administrators (civil servants), technical experts, representatives
of political interests and NGOs (and, in some countries,
religious leaders). Since the 1980s, in countries such
as Finland and Hungary, cardiologists and oncologists have
played a dominant role in NCD policy development, and to
some extent this has been evident in Lithuania and other
countries such as the Netherlands and the United Kingdom.
More recently, there have been attempts to make such
groups more interdisciplinary and to include, in addition to
public health experts, sociologists, economists and others.
In Hungary, this interdisciplinary approach was initiated as
early as the 1980s.
The preferred format seems to be that of a rather small
steering or coordinating group, sometimes with a broader
group acting as a sounding board and frequently with
subgroups dealing with special issues. For example, for
the broad health policy formulation in Ireland there was
a 17-person steering group, a 15-member project team, a
19-member high-level interdepartmental group and a small
international advisory panel; a suggested Cabinet subcommittee
was not active.
For the last 30 years, the WHO Health for All policy has
called for intersectoral bodies involving the main stakeholders
to formulate such policies, stating that “Unless those
who are to carry out health and development policies and
programmes also take part in their formulation and evaluation,
they will feel little commitment to putting them into
practice” (11). For many years, this has been easier said than
done and the health sector has dominated the process,
with token input from other sectors. When an attempt is
made to reach out to other sectors, the ”easy” partners
tend to be those included first.
In Hungary, it is usual to carry out a stakeholder analysis to
determine the members of the groups to be established to
tackle various aspects of NCD policy. Recently, in France, it
was decided to carry out a general consultation of stakeholders.
A commission was set up to make a thorough
analysis, including the strengths and weaknesses of the
disease prevention system, and the regions were asked to
comment on the draft. Few countries seem to go through
Chapter 5
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Reflections on experiences