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

Chapter 5
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aged to implement extremely strong legislative measures
and to obtain public acceptance of them, whereas Greece,
a tobacco-producing country, has not gone so far. What is
also important is that those countries with strong legislation
in place have also provided for the means to enforce such
legislation and to call to account those who do not observe
it. This includes heavy fines in some cases.
The impact of EU legislation for consumer protection is
particularly important, although in some countries such as
Finland this has had certain detrimental effects, examples
being the EU subsidizing full-fat milk in schools and more
lenient alcohol control regulations.
Certain legislative measures do not have important implications
for public funding. Possibly for this reason, in lowerand
medium-income countries such as Albania and Kyrgyzstan,
legislation may offer feasible entry points for starting
the implementation process.
Despite the development of the concept of health promotion
on an international level, traditional health education
measures still seem to dominate in countries such as, for
example, Albania and Greece. These are not always accompanied
by the necessary additional support measures
that international research has proved to be more effective.
On the contrary, the success of the Irish policy to prohibit
smoking in bars and restaurants was due to a combination
of health education on the dangers of passive smoking,
consultations with trade unions and the hospitality industry,
counteracting misleading claims by opponents, on-site visits
to places of work, discussions with enforcement agencies,
the establishment of fines for non-compliance, and the provision
of a list of named people to whom complaints could
be made.
Financial measures can be particularly effective, particularly
in relation to the price of tobacco and alcohol. Some
countries have taken the cost of tobacco out of the basket
of household goods used to calculate inflation. In all the
countries examined, policy implementation at the regional
or local level is at least partly financed by central funds. In
a number of cases, access to such funds has been linked
to criteria related to NCD policy implementation. Finland
offers a clear example whereby the loss of central control
over designated funding has created considerable inequalities
in policy implementation at the local level.
Protocols and guidelines
There is a growing development in Europe of protocols
and guidelines for tackling NCD, clearly influenced by work
in WHO and the EU. The scale ranges from international
protocols for breast cancer screening, through standards for
measuring and treating blood pressure, to the publication
of nutrition guidelines for schools, workplaces or various
high-risk groups. The WHO survey on national capacities
and policies to respond to NCD, referred to in Chapter
2, found that it was more common for countries to have
national protocols, guidelines or standards for diseases such
as diabetes, heart disease and cancer than to have the corresponding
policy instruments for weight control and physical
activity (25). Protocols for the care of NCD patients are
also becoming more widely available, but are apparently not
always regularly implemented.
Resources for policy implementation
Financial resources
The situation regarding designation of funding also varies
considerably among the case-study countries, from those
where financing is allocated for the full planning period to
those, such as Hungary, where funding can be designated
on a yearly basis through the annual budget. Other countries
make no mention of the financial resources necessary
for implementation, although the system of funding (if not
the amount) may be specified. The case-study countries
offer numerous examples whereby clearly designated funds,
or the lack of such funds, have determined the feasibility or
otherwise of policy implementation.
Reflections on experiences