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

Chapter 4
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any meaningful attack on the gaps between socioeconomic
groups, which continued to widen. The legislation freeing
the municipalities from close central direction had been
in preparation for about three years, but by the time it
was implemented the recession had already hit. School
education programmes were severely cut. Staff : children
ratios in day care and pupil : teacher ratios in schools were
enlarged. It took ten years to raise the level of hospital care
for children and young people to the level planned for 1990.
As the political climate for greater liberalization took hold,
it became more difficult to push for positive discrimination,
which has only recently reached the policy agenda. At
the same time, partly owing to the opening of the borders
through the Russian Federation to Afghanistan, a second
wave of drug misuse started in the early 1990s and has cast
a long-lasting shadow.
Recent changes in the Constitution have strengthened the
right to health and not just to health care, and health and
education are highly valued by the population. Finns are
also reasonably satisfied with the level and quality of health
care provided. Physicians and (particularly) surgeons are
the most highly respected professionals. Nurses are the
third most respected, although this is not reflected in their
remuneration.
There is a history of assessing the impact of policies in all
sectors on factors such as the environment, poverty and
gender, and HIA has found a niche in that process.
On the whole, there is public confidence in the state, its
civil servants and experts, partly owing to the extremely
low level of corruption. The “right to know” gives the public
a sense of control and policy leaders a sense of heightened
responsibility. As mentioned above, however, political
democracy at the municipal level has led to a lowering of
certain standards and increasing inequalities in the provision
of services.
Informal learning through the print media and the Internet
remains high, and on the whole the public is well-informed.
Membership of the EU and the constant need for reporting
and harmonizing regulations put a heavy burden on the
limited number of civil servants, no doubt distracting from
domestic issues. It also brought a threat to hard-won public
health measures, particularly in the areas of alcohol control
and nutrition. Finland made good use of this opportunity,
however, to put pressure on politicians. The rotating
presidency and membership of EU committees dealing with
issues of particular interest were judicially used. The EU’s
recently introduced open method of coordination (OMC)
is utilized as a means of both reviewing to some extent the
Finnish situation, and flagging up critical issues for discussion
with EU partners.
There are nevertheless looming concerns about the future.
These include emerging changes with an uncertain impact
on health, such as the pressure put on workers by the
“knowledge economy”; the amalgamation of municipalities;
the potential restructuring of institutions that have supplied
much of the research for health policy development; and a
growing private sector that may not keep health promotion
issues so high on the agenda. The question will be whether
the strands of policy development in tackling NCD, which
have so far been quite robust, can maintain a balance of
continuity with change, and whether the research and capacity
building resources for health development, described
as the “crown jewels” by one respondent, will be maintained.
5.2. Indications of the value system underlying policy
development
The Nordic welfare model has provided a strong and clear
framework of values for policy development. In the ten
years following the economic crisis of the early 1990s, opinion
polls indicated increasing support for the Nordic model.
Although sometimes coming into conflict with economic in-
Case studies: policy development in countries for tackling noncommunicable diseases