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

tation, and an important investment, the experience and
lessons learnt were never really used on a broader scale.
The North Karelia project in Finland continues, however,
to perform a pilot function for certain issues, even after so
many years of operation. The CINDI programme, particularly
as implemented in Lithuania, has also indicated the
value of testing complex NCD interventions on a small
scale through a demonstration site before expanding or
generalizing the approach.
Monitoring and evaluation
By monitoring we mean surveillance and recording of
observed changes, be they changes in epidemiological data,
steps taken towards administrative or legislative action, or
funds expended. Evaluation goes a step further, assessing
whether changes are in the right direction and if policy proposals
are being achieved in the sense of what went right or
wrong, and why and how.
As might be expected from the mixed picture of implementation,
the situation regarding the monitoring and evaluation
of NCD policy is equally mixed and rather less vibrant
than that of policy formulation. At one extreme, owing to
the initial stages of the policy development process as in
Greece, the newness of the policy as in Kyrgyzstan or the
failure to implement as in Albania, there is little yet to monitor
in policy terms. At the other extreme, in countries with
well-developed databases, a long history of well-functioning
surveillance systems and strong research institutions, such
as Finland, Ireland and Lithuania there is a well-developed
culture of monitoring and evaluating health policy. These
countries have a tradition of transparency in monitoring
progress in policy implementation and of reporting back,
frequently to parliament.
Approach
Changes in mortality rates are those most frequently
monitored, followed by changes in behaviour where this is
regularly surveyed. The impact of health promotion and the
uptake of screening programmes are evaluated in four of
the countries examined. There is less emphasis on monitoring
the functioning of the health system or the coordination
of policy implementation, although Finland and to some
extent Hungary try to do this.
In Finland, where there has been routine surveillance of
chronic diseases and their risk factors since the early 1970s,
a process has recently been instituted whereby each ministry
and level of government is obliged to report back on its
impact on health, thus contributing a strong intersectoral
aspect to the overall report to parliament on health policy
implementation. In Lithuania, the National Board of Health
reports annually directly to Parliament. Significantly in this
case, the Board enjoys a great deal of independence from
the Ministry of Health.
There has been annual reporting of progress in policy
development in Ireland since 2001. Different structures and
processes for monitoring and evaluation have been tried,
including a high-level Cabinet Subcommittee (which was
not so successful), interdepartmental group reviews and
reports, the regular reporting of the National Implementation
Team; and reports of specially constituted task forces
reporting on issue-specific policies.
One of the encouraging developments is that, where a
system of monitoring and evaluation is in place, this is usually
reflected in published documents in a transparent and
accessible way. The Internet offers a new possibility for a
broad accessibility of published monitoring and evaluation
results. In Hungary, for instance, some public health reports
and other monitoring results of the National Public Health
Strategy are available on the Internet, although so far without
special attention to their interest for the general public.
In Finland, France, Ireland and Lithuania, policy documents
stated that an interim review should be carried out part-
Chapter 5
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Reflections on experiences