Gaining Health Analysis of policy development in European countries for tackling noncommunicable diseases By Anna Ritsatakis and Péter Makara Editors: Jill L. Farrington, Robert Geneau and Bosse Pettersson Gaining health Analysis of policy development in European countries for tackling noncommunicable diseases By Anna Ritsatakis and Péter Makara Editors: Jill L. Farrington, Robert Geneau and Bosse Pettersson Abstract There is no greater threat to the health of people in the WHO European Region than that of noncommunicable diseases, yet this is an area where the greatest health gains are available at relatively modest cost. This book gives a detailed insight into the policy development in eight European countries over several decades to address the challenge of noncommuni- cable diseases, and draws out the main themes to assist policy-makers in formulating their own response. While originally developed to support countries in the implementation of the WHO European Strategy for the Prevention and Control of Noncommunicable Diseases, the insights are likely to be of benefit to a much wider audience. Keywords CHRONIC DISEASE - prevention and control ISBN 978-92-890-4179-9 heALth PROMotion heaLth POLicY - analysis poLicY MAKinG nationaL HEALth PROGraMS prOGraM DEVELopMenT EUrope Address requests about publications of the WHO Regional Office for Europe to: Publications WHO Regional Office for Europe Scherfigsvej 8 DK-2100 Copenhagen Ø, Denmark Alternatively, complete an online request form for documentation, health information, or for permission to quote or translate, on the Regional Office web site (http://www.euro.who.int/pubrequest). © World Health Organization 2009 All rights reserved. The Regional Office for Europe of the World Health Organization welcomes requests for permission to reproduce or translate its publications, in part or in full. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either express or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. The views expressed by authors, editors, or expert groups do not necessarily represent the decisions or the stated policy of the World Health Organization. Contents Page Abbreviations iv Foreword v Preface vi Contributors viii Chapter 1 Introduction 1 Péter Makara Chapter 2 History and context of policies to tackle NCD 5 Péter Makara & Jill L. Farrington Chapter 3 Methodology, underlying concepts and values 13 Anna Ritsatakis iii Chapter 4 Case studies: policy development in countries 25 for tackling noncommunicable diseases Albania – Péter Makara & Zsófia Németh 26 Finland – Anna Ritsatakis 38 France – Zsófia Németh 75 Greece – Anna Ritsatakis 99 Hungary – Péter Makara & Zsófia Németh 128 Ireland – Anna Ritsatakis 149 Kyrgyzstan – Péter Makara 178 Lithuania – Anna Ritsatakis 189 Chapter 5 Reflections on experiences 215 Anna Ritsatakis & Péter Makara Chapter 6 Pointers to the future 253 Péter Makara & Anna Ritsatakis Abbreviations The abbreviations shown below are those of a general nature that are used in the book. Others pertaining to individual countries are explained under the relevant case studies. AGE European Older People’s Platform GDP gross domestic product BSE bovine spongiform encephalopathy GHPS Global Health Professional Survey CDC Centers for Disease Control and Prevention GNP gross national product CHD coronary heart disease GP general practitioner CINDI co untrywide integrated noncommunicable GYTS Global Youth Tobacco Survey diseases intervention (programme) HIA health impact assessment CSR corporate social responsibility IAEA International Atomic Energy Agency CVD cardiovascular diseases IARC International Agency for Research on Cancer DALYs disability-adjusted life-years IUHPE International Union for Health Promotion and DFID United Kingdom Department for International Education iv Development KRIS Kaunas-Rotterdam Intervention Study ECHO European Commission’s Humanitarian Aid MDGS Millennium Development Goals Office MONICA Multinational Monitoring of Trends and ECHI European Community Health Indicators Determinants in Cardiovascular Disease EFTA European Free Trade Association NAP national action plan for social inclusion ENHPS European Network of Health Promoting Schools NCD noncommunicable diseases ENWHP European Network for Workplace Health NGO nongovernmental organization Promotion OECD Organisation for Economic Co-operation and EPIC European Prospective Investigation into Cancer Development and Nutrition OMC EU’s open method of coordination EU European Union PHARE Assistance for Economic Restructuring in the EU15 the 15 countries belonging to the EU before May Countries of Central and Eastern Europe 2004 PHC primary health care FCTC WHO Framework Convention on Tobacco PPP purchasing power parity Control SDR standardized death rate G8 Group of Eight USAID United States Agency for International Development Foreword There is no greater threat to the health of people in the WHO European Region than that of noncommunicable dis- eases (NCD), yet this is an area where the greatest health gains are available at relatively modest cost. An upstream focus on the social determinants of health and prevention of risk factors common to several NCD, as well as more widespread implementation of effective interventions for managing disease, is likely to bring considerable benefit to the health and well-being of society. At the fifty-sixth session of the WHO Regional Commit- tee for Europe, Member States unanimously endorsed the WHO European Strategy for the Prevention and Control of Noncommunicable Diseases. This book derives from their request to the WHO Regional Office for Europe to sup- v port Member States in the implementation of the Strategy through, among other things, facilitating the exchange of information on evidence and best practice with a focus on policy development and implementation. Through a set of case studies, this book analyses policy development in eight countries over several decades to address the challenge of NCD, and then develops the main themes from these and elsewhere in order to broaden understanding of the policy-making process and conditions that influence it. I welcome this approach and am convinced that this book will provide an invaluable resource for policy- makers in formulating their own response. Although Europe is diverse, and capacities differ, it is possible for all countries across the Region to effectively combat NCD. Agis D. Tsouros Noncommunicable Diseases and Environment WHO Regional Office for Europe Preface The WHO European Strategy for the Prevention and Con- The present piece of work was born out of this challenge, trol of Noncommunicable Diseases, endorsed by WHO and sought to find answers to the questions so often posed European Member States in 2006, was a landmark strategy by countries. What is an NCD policy in reality? Is an overall, in a number of ways. First, it was prepared over a period integrated NCD policy necessary? Are there certain basic of almost two years in what was described as “a unique prerequisites for the successful development of NCD participatory and transparent manner”.1 Fifty-one countries policy? Furthermore, this work set out to explore the evo- appointed national counterparts specifically to work with lution of policies in countries over time. How does a coun- WHO on its development, drawing on expertise from the try develop a comprehensive approach to tackling NCD? fields of health policy, public health, health promotion, dis- While we had information from surveys of countries on the ease prevention and clinical medicine. A drafting group with range of policies and programmes in place, these were just participants from eight countries was appointed, meeting snapshots and the richness of the picture was missing. How nine times and developing three drafts for consultation. and why had this present collection come about? How did these different instruments work together? Where should Second, the Strategy took an integrated approach to a country start? And what experience was available from vi prevention, focusing on social determinants of health and other countries to assist them? We are grateful to the au- risk factors common to several noncommunicable diseases thors in taking up this challenge and for their hard work and (NCD). Prior to this, WHO strategies and action plans had enthusiasm in working to find answers to these questions. largely focused on individual risk factors. Third, it was one of the most comprehensive