Health Targets In Europe: Polity, Progress and Promise

Health Targets in Europe: Polity, Progress and Promise Edited by Marshall Marinker Visiting Professor of General Practice, Guy’s, King’s and St Thomas’ Hospitals Medical and Dental School, King’s College London

© BMJ Books 2002 BMJ Books is an imprint of the BMJ Publishing Group All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording and/or otherwise, without the prior written permission of the publishers. First published in 2002 by BMJ Books, BMA House, Tavistock Square, London WC1H 9JR www.bmjbooks.com

British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library ISBN 0 7279 1642 4 Typeset by Newgen Imaging Systems (P) Ltd., Chennai Printed and bound in Spain by GraphyCems, Navarra

Contents

Contributors Acknowledgements

v vii

1

Evidence and imagination Marshall Marinker

1

2

Historical perspectives on European health and policy Loes van Herten and Louise J Gunning-Schepers

18

3

For and against health targets James McCormick and Naomi J Fulop

34

4

Sweden Claes Örtendahl

49

5

Lithuania Vilius Grabauskas

69

6

Spain Carlos Alvarez-Dardet

76

7

Germany Hans Stein

89

8

North Rhine-Westphalia Birgit Weihrauch

103

9

Finland Seppo V Koskinen and Tapani A Melkas

117

iii

CONTENTS

10 Italy George France

130

11 England David J Hunter

148

12 A European review Morton Warner

165

13 Values, beliefs, and implications Martin McKee

181

14 Perspectives on health governance in the 21st century Ilona Kickbusch

206

Index

231

iv

Contributors

Carlos Alvarez-Dardet Professor of Public Health, Alicante University, Spain and Editor of the Journal of Epidemiology and Community Health George France Senior Researcher, Institute for Regional Studies, National Research Council, Rome, Italy Naomi J Fulop Senior Lecturer in Health Services Delivery and Organisational Research, Health Services Research Unit, London School of Hygiene and Tropical Medicine, London, UK Vilius Grabauskas Professor and Rector, Kaunas University of Medicine, Lithuania Louise J Gunning-Schepers Chairman of the Executive Board, Dean of the Faculty of Medicine, the Academic Medical Centre, University of Amsterdam, the Netherlands David J Hunter Professor of Health Policy and Management, University of Durham, UK Ilona Kickbusch Division of Global Health, Department of Epidemiology and Public Health,Yale School of Medicine, Connecticut, USA Seppo V Koskinen Senior Researcher, National Public Health Institute, Helsinki, Finland James McCormick Emeritus Professor of Community Health, University of Dublin, Ireland Martin McKee Professor of European Public Health, London School of Hygiene and Tropical Medicine, London, UK v

CONTRIBUTORS

Marshall Marinker Visiting Professor of General Practice, Guy’s, King’s and St Thomas’ Hospitals Medical and Dental School, King’s College London, UK Tapani A Melkas Director, Section for Health Promotion and Disease Prevention, Ministry of Social Affairs and Health, Helsinki, Finland Claes Örtendahl Director General of Health, Sweden (until 1998), Department of Public Health Sciences, Karolinska Institute, Stockholm, Sweden Hans Stein Head of EU Health Policy Division, German Ministry of Health, Bonn, Germany Loes van Herten Epidemiologist, TNO Prevention and Health, the Netherlands Morton Warner Director and Professor of Health Strategy and Policy, Welsh Institute for Health and Social Care, University of Glamorgan, South Wales Birgit Weihrauch Head of Division for Health Policy and Health Protection, Ministry of Women,Youth, Family and Health, North Rhine-Westphalia, Germany

vi

Acknowledgements

I have many people to thank. In 1997 Merck & Co., Inc., Whitehouse Station, New Jersey, USA* brought together an Academic Advisory Board to give independent advice to, and oversee, its European Health Targets Research Grant Programme. The programme was designed to promote the concept of health targets as a policy tool in Europe and to encourage young researchers in this field.The programme has already supported some 21 projects representing a wide range of topics and approaches concerned with health targeting throughout Europe at a variety of administrative levels – municipal, regional, national, and international. I was invited to chair the Board, the current members of which are: Professor Arpo Aromaa (Finland); Dr George France (Italy); Professor Dr Klaus-Dirk Henke (Germany); Professor Ilona Kickbusch (USA); Professor Morton Warner (UK); Professor Stipe Oreskovic (Croatia); Dr Miquel Porta (Spain). Dr Andrzej Rys (Poland) resigned in 1999 on his appointment as Deputy Minister of Health. It was from discussions at the meetings of this Board, and at associated workshops and conferences, that the idea for this book was born. It is a great pleasure to thank my distinguished colleagues on the Board for their key contribution to the generation of this book, for the good fellowship of the past four years, and also for the patient education of their chairman. The book has been generously supported by an educational grant from Merck & Co, Inc, Whitehouse Station, New Jersey, USA. I owe an especial debt of gratitude to Dr Jeffrey L Sturchio (Executive Director, Public Affairs, Europe, Middle East & Africa) for his stimulating interest in health policy and his encouragement and enthusiasm. Melinda Hanisch (Manager, European Public Affairs) has been endlessly helpful in her administrative support for the Board, the research grants, and the book.

*Merck & Co., Inc. operates in most countries outside North America as Merck Sharp & Dohme, or MSD. vii

ACKNOWLEDGEMENTS

Professors Martin McKee and Morton Warner have acted as special editorial advisors, have commented on early chapter drafts, and have made many helpful recommendations for clarification and additional material. Professor Ilona Kickbusch was kind enough to read an early draft of my own chapter and her knowledge and wisdom have saved both the readers and me from a number of embarrassing errors of fact and judgement. I thank all the authors – for their dedication in meeting my deadlines, for their forebearance in the face of my editorial pernicketiness, and for the quality of their contributions. Mary Banks (Commissioning Editor, BMJ Books) has yet again proved a wonderful support and a model of what any author or editor could hope for in a publisher. Marshall Marinker

viii

1: Evidence and imagination MARSHALL MARINKER

“How do we want to live?” In her concluding chapter, Ilona Kickbusch quotes this challenge from Ulrich Beck to late modern societies.1 In the course of putting this book together, I found that it was this question, in many different guises, that engaged the writers and lies at the heart of the entire health targeting project. In 1977 the World Health Organization launched its “Health for All by the Year 2000” campaign and proposed a number of broad health targets as part of a strategy to promote the health of people throughout the globe. By 1984 all the countries in the region had adopted the 38 HFA targets proposed by WHO Europe. Many other variants of health targeting have followed at the international, national, and regional levels. All are concerned with a wide variety of factors and preconditions – the impact on health of education policy, the environment and ecology, demography and epidemiology, human behaviour, access to health services, and politics. In Europe, health targeting has over the past years played an increasingly important role in health policy and governance at every level from the European Union to the municipality. A number of evaluations of the ensuing activities have appeared in recent years.2–4 The WHO refers to five key influences on health: biological factors; lifestyle; the physical environment; the social environment; and access to, and quality of, health care. Health targets are described as specific, quantifiable and measurable objectives designed to improve the health of individuals and families, of communities, and of regional and national populations.They are derived from an interplay between epidemiological evidence, moral values, and political will. Yet the desired characteristics of the processes and outcomes of targeting (specific, quantifiable, and measurable) do not always fit easily with the spread of motives that are necessary to give them 1

HEALTH TARGETS IN EUROPE

impetus (epidemiological evidence, moral values, and political will). Further, although targets were intended to be specific and measurable, they have as often been expressed in terms that are broad and aspirational. Far from providing tightly engineered managerial tools, many administrations have created targets in the form of political promissory notes. When I drafted the proposal for this book I gave notice that the multilayered concepts included in the term health targets seemed so rich and diverse that the book should necessarily begin with an absence of defined and agreed boundaries. If that is how a book begins, that is also how it will, and should, end – with an unfinished exploration of what can be agreed and what is best to leave open. The plan was to assemble here an account of health targets in a variety of European settings, their implementation and the lessons to be drawn. However, because of the wide diversity of definitions of “health target” and the sweep of intentions in “targeting”, a second strong theme emerged. In so many of their essays it appeared that the writers were driven to examine the ambiguities and extended possibilities of the language employed in health targeting. Words were clearly being interpreted either to expand or contract the possibilities for action. There was a need to challenge their meanings. Further, just beneath the surface of much of what is reported and discussed here, a third theme emerged. In considering the specifics and practicalities of health targeting throughout Europe, many writers seemed to be searching for some archetypically European tradition and idealism about health and its promotion in our societies. Martin McKee deals extensively with this in his chapter, but many other writers allude to it. Why we should be concerned with such a search, and what myths impel it, may perhaps be revealed in what follows. All three of these themes were then retrospectively adopted in the light of the evidence and experience of the writers. The targets for the book were redrawn in the light of where the arrows had fallen. What struck me was how faithfully this process of modification and reinvention in the construction of the book mirrored, as we shall see, what happens in the course of constructing targets for health and attempting to implement them. Neither a book nor a health target is subject to a linear and predictable course. Books and health targets exist in a perpetual state of transition – long after the book is published, long after the target has been hit or missed or redrawn. 2

EVIDENCE AND IMAGINATION

Minding our language Writers must mind their words – not least when, as in the case of health targeting, their subject matter is so linguistically loaded. That is why I begin with the language of health targeting. An example is the numerical escalation of intentions in the WHO’s Health 215: … one constant goal is to achieve full health potential for all people in the Region, with two main aims: to promote and protect people’s health throughout their lives; and to reduce the incidence of the main diseases and injuries and alleviate the suffering they cause.Three basic values form its ethical foundation: health as a fundamental human right, equity in health and solidarity in action, and participation and accountability for continued health development. Four main strategies for action have been chosen to ensure that scientific, economic, social and political sustainability drive the implementation …

These are grand words and we return constantly to them throughout the book. But how are we to understand them? Susan Sontag6 warns about the awesome power of words. She was actually commenting on the bitter conflict between Israelis and Palestinians, but she was also making a much wider and historic point about the power of words to hurt or heal, to build or destroy: We fret about words, we writers. Words mean. Words point. They are arrows. Arrows stuck in the rough hide of reality. And the more portentous, the more general the word, the more they also resemble rooms or tunnels. They can expand, or cave in. They can come to be filled with a bad smell. They will often remind us of other rooms, where we’d rather dwell or where we think we are already living.

Her message becomes clearer when she goes on to examine, with due scepticism, the vocabulary of nationalism – words like “liberty”, “peace”, “honour” and “rights”. These are magisterial words: they mean, they point, they are arrows. As indeed are many of those employed in this book – words like “equity”, “solidarity”, “rights”, “freedom”, “individual” and “society”. A majority of the writers in this book were not writing in their own language. They were, however, all experienced academics, very much at home in what has become a lingua franca of science, politics and much else in the world – the English language. But of course, they came to the use of English out of the underlying cadences and habits of thought embedded in the tradition of other (their native) tongues. As editor, and embarrassed by the sense of inadequacy and guilt that we native Anglophones feel in the face of our multilingual fellow 3

HEALTH TARGETS IN EUROPE

Europeans, my job was to edit the text and render the originals into a generally accessible English prose. The challenge was often to choose quite different words and phrases from those initially employed, while straining to keep absolute faith with precisely what I believed the author was intending to say. This editorial task, far from being irksome, became increasingly instructive. I found that my fellow authors were having difficulties similar to my own. These seemed to relate not so much to the task of translating their thoughts into English but rather to the ambiguities inherent in their own words – and to the ambivalences that these words engendered. It struck me that even when we think and speak in our own native tongues, we are always translating. I came to suspect that it would be from these very approximations, ambiguities, and ambivalences that we might reach a richer lingua franca in which to talk about, and to cooperate in, the new imperatives of European health polity. The linguistic codes of the health professionals can further confuse. Examples from clinical medicine and health policy suggest how these can shape or deform our thinking. Throughout the 20th century doctors came to abandon the earlier language of natural observation and to prefer that of experimental science. At the dawn of the 21st century the clinician seems to have far greater confidence in the terms of blood chemistry, imaging technology, and the genome than in words that speak of the appearance, let alone the experience, of the suffering patient. As for the vocabulary of health policy (health targeting serves well as an illustration), this can bleach the vibrant coloration of our hard choices and tragic consequences. The English poet TS Eliot, looking bleakly at the passing of years, wrote: “I have measured out my life with coffee spoons”.7 The health economist leaves me with no such sardonic comfort. He invites me instead to measure out my life not with coffee spoons but with quality-adjusted life years.8 In almost everything written in the chapters to follow, the languages of science and art contend. Jacob Bronowski9 describes scientific language as “single valued”. A scientific language, he says, is restricted to saying precisely what something means and only that. Its strength is in its necessarily restricted precision. The physicist and chemist and biologist require symbolic language – with no room for dispute. The term Hg refers to the specific physical characteristics of the element mercury – its atomic weight and so on. It must remain silent on such matters as its shimmering silver white 4

EVIDENCE AND IMAGINATION

appearance, its weird liquidity, its haunting semantic reference to the Roman god of eloquence and feats of skill, the protector of traders and thieves. Bronowski describes “natural” language, what could be described as “unrestricted” language, as multivalued. When we express ourselves in French and German and Italian and English and the rest, we are capable of alluding to everything that the words we use could possibly mean – the richness lies in the many semantic references and overtones. It is a paradox that while natural language, because of its historical nuances, expands the horizons of our imagination, it contracts our capacity to communicate with any possibility of accuracy. It is a further paradox that while the evidence on which most health targeting is predicated is properly expressed in the language of science, arguably the most important outcomes which we seek can be given full voice only in the unrestricted and gloriously imprecise use of our natural and native languages. The proclamation of Health 21 begins with awesome ambition: the “one constant goal is to achieve full health potential for all people in the Region”. The English novelist Katherine Mansfield, already dying of tuberculosis as a young woman in the 1920s, described her personal health goal in similar terms. She wrote: “I want to be all that I am capable of becoming”. She was not, I think, announcing a realistic benchmark for future monitoring. Like the opening of Health 21, she was making what today we would call a mission statement. Mission statements are there to inspire, to give us values to live by, to convey an ideal as spirit rather than task. This is echoed by many of our authors here. For example, Ilona Kickbusch: “Increasingly target setting became a technocraticprofessional-managerial enterprise rather than a process to set in motion the acceptance of new political priorities … ”. Claes Örtendahl: “Targets are used … symbolically (to mark a common interest) rather than technically”. Birgit Weihrauch: “ … the process of targeting, quite apart from the primary intention of the targets in terms of health gain, has been of substantial benefit to the functioning of the health system”. David Hunter is more ambivalent: “While targets should be challenging they should also be achievable and not so aspirational that they are of symbolic value only” but later writes: “Targets … may achieve more as a symbol of policy than as precise instruments designed to implement policy to the letter”. Hans Stein and Loes van Herten both quote Peter Drucker: “Targets can be compared to the compass bearing by which a ship navigates”. 5

HEALTH TARGETS IN EUROPE

Targeting health and illness While we may strive to quantify the appearances of disease, health cannot be so mathematically expressed. WHO has defined health in the broadest of terms: it is to be understood as more than the absence of disease but as a positive sense of well-being that embraces every aspect of life – physical, emotional, and social. If health, as here defined, is a proper and important aim of policy and governance, a view affirmed in most of the essays in this book, we will need more than epidemiological tools to express the targets and their consequences. A decaying, culturally and socially impoverished inner-urban district is transformed as the result of a successful cooperation between the city’s public, private, and voluntary organisations. Social capital is invested. There are now play areas, public gardens, locally owned corner shops, light industry workshops, a primary healthcare centre, a crèche, a social and sports club, and safe cycling routes. The substantial gain in public health is instantly apparent in the demeanour of the mothers and children, the tone of voice in the streets, the greenness of the grass. But these are not easily measurable. The question for health targeting is whether we restrict our choice of targets to those we can measure with confidence or choose the targets that we wish to achieve and settle for indirect intimations of success. Much in the current technomanagerial value system of health governance drives us towards the first option. But Koskinen and Melkas, defending the Finnish preference for qualitative rather than quantitative targeting, write that qualitative targets did not “ … entail the risk of only emphasising what is measurable, and sacrificing as a consequence, what is important”. Kickbusch writes: “From its inception, target setting was hampered by this marriage of epidemiology and managerialism that it has never quite been able to shake off ”. This “marriage” has also posed difficulties for the public health practitioner. In an essay on public health advocacy Crown and Gunning-Schepers wrote: As this sense of … involvement in the corporate structure grows it may be increasingly difficult for public health practitioners to fulfil the functions of the “conscience of the organisation”, the “poet in residence”, or the “critic of the system”. In this role, the public health practitioner holds up a mirror to the organisation itself and helps it to be self reflective about its aims and objectives, structures and processes.10 6

EVIDENCE AND IMAGINATION

In much that is written about health targeting, there is a confusing ambivalence about the role of health services in achieving the goal of improving health. The history of the hospital in Europe throws some light on this ambivalence. In the ancient world hospitals were temples to the deities of healing. The Roman Empire established valetudinaria for its sick or injured soldiery. With the advent of the Christian era, hospitals were first organised by the monks and in the Middle Ages, with the mounting of the Crusades, their number later grew. Later still, with the rise of nation states, these institutions were required to deal with new threats to social order, as the lazar houses had been used to hide the lepers. It became necessary to “contain” those with infectious diseases, the mad, and the indigent poor. The lazar houses became vacant as leprosy receded from Europe and in the 18th century hospitals were essentially sequestered houses for these health dissidents and, in 19th century England, workhouses. It seems that the social space which the modern hospital occupies has had some unexpected tenants in the past. The hospital as an emblem of state power is echoed in Carlos Alvarez-Dardet’s contention that the ultimate achievement of health policy by the dictator Franco was “ … the creation of mammoth hospitals in the bigger Spanish cities, with some thousands of beds, as the flagships of the regime’s health policy”. In this, the hospitals became the 20th century metaphors for the castles, cathedrals, royal palaces, and memorial arches of earlier times. There seems little in such triumphalist gestures to enhance health. Yet in the UK, for example, the great teaching hospitals seem to stand as talismans of health in the public imagination. While so many health policy experts aver that medical services have only a secondary role in the pursuit of health, to what extent is this view shared by the electorates? Hans Stein reminds us that health is the most sensitive of cultural and political issues but for as long as I can recall, the electorate in the UK has demanded, and party politicians have earnestly promised, more and better hospitals, shorter waiting times, and access to all the latest and most effective medicines and surgical procedures. The term “health service” is most widely understood by electorates as a synonym for disease service. It is hard to detect a loud public clamour for political action to counter cigarette smoking, to encourage immunisation, to moderate alcohol consumption, to promote physical exercise, and to encourage healthier diets. Yet I am grateful to Ilona Kickbusch for reminding me that at the heart of the working class movements in Europe there 7

HEALTH TARGETS IN EUROPE

was concern not only for freedom of access to medical services in times of illness but also for health – for better living and working conditions – and that these historic imperatives can live on in the collective unconscious. However powerful the effect of the environment and the modification of human behaviour in determining health, and however many of our writers regret the past dominance of the medical voice in the counsels of public health, there may be persuasive reasons for recognising that the quality, and indeed the equity, of health services are key factors in the health of people. Mental states seem to act no less powerfully than biological states in our perceptions of our own health. The provision of state-of-the-art health services may well give the public a deep sense of security from the depredations of morbidity and mortality, however uncertain the evidence for such benefit.

Fairness and freedom Perception also seems to play a crucial role in the link between health and wealth. Ivan Illich11 asserts that health is not a commodity peddled by doctors but rather another way of describing culture. Therefore to say that the poor have poorer health than the wealthy seems merely to utter a tautology. In population terms, the component elements of poor health and poverty largely overlap. Little surprise therefore that concerns for equity, and the mechanisms of solidarity, appear throughout the health governance literature. Equity carries overtones of social equality, distributive justice or fair shares and can be used to refer to the health needs of populations or to individual deserts. How are we to talk about a fair share of health? Peter12 notes that there are two dominant models of health. The first he calls positivist, referring not to philosophical positivism but to the idealistic promotion of a positive sense of well-being, as in the WHO definition. The second he calls biomedical, referring to the avoidance of diseases. Neither of these, he says, is sufficiently concerned with the problem of equity. He suggests a third model, which he describes as health as freedom. In this he brings together elements of both the positivist and the biomedical and adds the dimension of our capacity for well-being. He argues that Amartya Sen’s distinction between well-being and agency helps to redefine health: In other words, health is a form of freedom, and disease needs to be understood in relation to how those experiencing it feel constrained in their 8

EVIDENCE AND IMAGINATION

freedom to pursue what they perceive as valuable. Canguilhem13 calls health a “biological luxury”. Disease is not simply a deviation from the norm that is health, but a new norm of life. What it entails, however, is a reduction in a person’s abilities to cope with environmental changes; a reduction in freedom.

It is one thing to consider with due concern an inequitable distribution of well-being in society. The idea of an inequitable distribution of freedom is altogether more alarming. The “health as freedom” model frees us from the comparatively narrow confines of functional outcomes for their own sake and impels us to set targets which enhance the capacity of individuals.We know, for example, that if we wish to improve the health of underprivileged children we must first educate (empower) the mothers. This model of health seems to me to suggest a persuasive rejoinder to James McCormick’s libertarian critique of health targeting, in his exchange of letters here with Naomi Fulop. McCormick suggests that health targeting, and in particular our preoccupation with the avoidance of health risks at the population level, diminishes personal freedom. Elsewhere he has complained of “ … a new and growing health fascism”.14 His colleague Petr Skrabanek15 coined the term “coercive health”. There is of course a tension between the freedom of the individual and the policies for public health. Yet what quality of freedom can be enjoyed by the citizen whose quality of health has been its price? Does “health as freedom”, the empowerment of the individual, the enhancement of the individual’s capacity for health, resolve the problem of fair shares of health? A number of researchers have detected that the causes of the health differences between the social classes may go deeper than the level of their access to material goods. In a paper on income distribution and life expectancy, Wilkinson16 concludes: “The social consequences of people’s differing circumstances in terms of stress, self-esteem and social relations may now be one of the most important influences on health”. In an article called “Justice is good for our health”17 a group of authors, including Amartya Sen, write: One especially important factor in explaining the health of a society is the distribution of income: the health of a population depends not just on the size of the economic pie, but on how the pie is shared. Differences in health outcomes among developed nations cannot be explained simply by the absolute deprivation associated with low economic development – lack of access to the basic material conditions necessary for health such as clean water, adequate nutrition and housing, and general sanitary living conditions. 9

HEALTH TARGETS IN EUROPE

The degree of relative deprivation within a society also matters … Wealthy countries with more equal income distributions, such as Sweden and Japan, have higher life-expectancies than does the United States, despite their having lower per capita GDP. Likewise, countries with low GDP but remarkably high life-expectancy, such as Costa Rica, tend to have a more equitable distribution of income.

There is something here beyond the calculations of epidemiologists and economists: a psycho-socio-political health factor which may prove as difficult to qualify, and as impossible to quantify, as the “tone of voice in the streets” and “the greenness of the grass”. But if we cannot directly or securely measure the outcome of building social capital, should we abandon the experiment and rather invest only in what we believe we know, because we have limited our ways of knowing?

Politics and evidence In many countries, especially those undergoing rapid political transformations, frequent changes of government inevitably bring the risk of confusion as the ebb and flow of contrasted political values influence strategy. To be effective and sustainable, health targeting seems to require a particularly sensitive and balanced partnership between politics and science. In at least two of the examples given in this book, the involvement of health experts exercised a stabilising effect on changing governments. In the case of Lithuania, Vilius Grabauskas comments that the inclusion of leading public health academics in the work of government bodies seems to have afforded some considerable measure of science based coherence and continuity in health policy. Similarly, Hans Stein notes that in Germany the “process has been influenced by an intensive and transparent dialogue between the scientific public health community … and health policy decision makers … ”. Carlos Alvarez-Dardet, however, tells us that in the case of Spain, the extent to which the government of the day took an authoritarian, libertarian or collectivist view quite powerfully impacted on current health policies. Is health targeting in modern Europe, then, an expression of the political left and inimical to the libertarian right? This seems to be hinted at by a number of our authors. Referring to recent UK government health policy documents, Ilona Kickbusch comments that these policies: “ … are value based and equity oriented, both were only possible with a social democratic/labour government in power”. 10

EVIDENCE AND IMAGINATION

But must we continue to be constrained to think about the future direction of European health policy as a matter of collectivist or libertarian political preference? Because if we are, then the inevitable merry-go-round of political parties in power will drive our endeavours in a confusion of directions. Can we move the political debate about health policy onto other ground? The examples of cooperation between politicians and health scientists in Lithuania and Germany are encouraging. Would health policy and targeting be safer if largely taken out of the hands of politicians and placed firmly in the stewardship of the experts? I suggest not necessarily. We live in the age of evidence-based medicine and there is a consensus that all future policies must be securely anchored in scientific evidence. Indeed, justice seems to demand it.Yet this proper respect for the evidence can, if reified to the status of a natural law, also stultify innovation and shelter us from important surprises. The history of scientific discovery is full of examples of the ways in which habits of thought can deceive. To give a recent example, it has long been received wisdom that the rising prevalence of childhood asthma closely paralleled our increasingly polluted environment and major funds have been devoted to the study of this relationship. Only standardised comparisons of the major international differences in asthma prevalence revealed that these are not so easily explained by “ ‘established’ risk factors such as air pollution, but are more consistent with recent theories on the protective role of some infant infections in the aetiology of asthma”.18 I think that it was Goethe who commented that Man is prone to see only what he already knows. Scientific data, no less than the policy inferences we draw from them, are not simple objective rock-solid facts quarried from nature. They are also social constructs.19,20 Innovators must always be prepared to run ahead of the evidence or at least to realise that an absence of evidence is an invitation to experiment, not an alibi for conservative inaction. All inventions, not only in science and technology but also in public policy, begin with acts of the imagination. And so should health targets.

Governance and imagination Governance refers not only to the exercising of “mastery”, “control”, and “good order”, but also to the manner of governing. Many of our authors here, in reporting on the processes of health targeting in their several countries, have warned of the stultifying effect of a rigidly 11

HEALTH TARGETS IN EUROPE

bureaucratic interpretation of what should be done and how. Gareth Morgan21 suggests that we can choose between an array of contrasted “images of organisation”. Our organisations replicate the metaphors by which we choose to work and live. He describes the machine (with its central controls, predictable functions, and hierarchical structures) as the dominant organisational metaphor for most of the 19th and 20th centuries. Other models in his taxonomy include the organisation as biological organism, as psychic prison, and as brain. The organisational demands of health targeting now – subsidiarity, transparency, intersectoral cooperation, public–private partnerships, participation, flexibility, innovation and so on – will demand that we explore new forms (new metaphors) of governance for health. These new forms of governance will not be able to grow if they attempt to reproduce the rigidly linear cause and effect management of the Industrial Revolution. Reviewing the work of Amartya Sen on “the standard of living”, a concept close to “health”, Geoffrey Hawthorn22 comments: The value of “the living standard”, as he [Sen] puts it, “lies in the living”. And if that means, against some prevailing academic fashions, that we have to reject being precisely wrong in favour of being vaguely right, so be it. … Much of what falls within “the standard of living”, like much of living itself, may not admit much empirical precision. And even if it did, such precision would usually have little point for those in government, who act with instruments that are blunt in conditions which they only fitfully control.

Just how blunt the instruments, and how illusive the precision, is touched on by Örtendahl: To be effective targets need to stimulate a process of public health work. Targets that only focus on outcomes (for example, to reduce cervical cancer incidence by 25%) indicate little or nothing of the causal factors that must be influenced in order to achieve the target. I would argue that outcome targets alone are rather ineffective in stimulating the actions required to achieve them … In a sense the idea of targets, measurements, and corrections had its apotheosis in Soviet style planning for industry and economic development.

Ilona Kickbusch makes the search for a new form of health governance a major theme in the final chapter – a form that must be consonant with the massive social and technological transformations of 21st century Europe. What we await are new definitions of inclusivity, transparency, leadership, and equity which can articulate the virtual institutions already forming on the Internet. Morgan 12

EVIDENCE AND IMAGINATION

describes such imaginative recasting of our working structures and processes as “imaginisation”. The Health 21 values – “health as a fundamental human right, equity in health and solidarity in action, and participation and accountability for continued health development” – can only be instrumentalised now in a form of health governance based on a fresh approach to the categories of relevant data and the means of direct action – a new amalgam of broad ecology and local politics. Ilona Kickbusch, Martin McKee, and Morton Warner point us in this direction.

Europe The assumption of a “human right” to health underpins much of what has been written in the following chapters. Yet in earlier centuries, far from being a right, health was rather a duty. It was the duty of the subject to preserve their health in the interest of the state and it was the policy of the state to help them to do so. In 16th and 17th century Europe, mercantilism emerged as the major political theory. The power of the state depended on maximising its acquisition of wealth, its ability to amass and retain bullion. The link between politics and health was soon apparent. For example, in 1668 Johann Joachim Becher, a German physician, chemist and writer on political and economic subjects, published a discourse on the rise and fall of cities and states. He laid great stress on the necessity of populousness. Throughout Europe, the realisation dawned that the economic power of the state, and hence its ability to defend itself, depended on fostering the growth of healthy populations. How the European public health movements grew out of this mercantilism has been chronicled by George Rosen.23 In this tradition, concern was for the health of the nation state.The individual was simply the basic unit of the state, that part of the state which could not be further divided.The meanings which we now attach to the term “individual”, which refer to entitlements – autonomy, privacy, liberty, and so on – are historically speaking relatively recent. Rosen’s seminal history traces the growth of these mercantilist (and cameralist) preoccupations. They originated in the value placed by political theorists on populousness in relation to the wealth and strength of the 18th century European nation state. He ascribes to Wolfgang Thomas Rau, a municipal physician in Ulm, the first use of the term “medical police”, which became so central in the developing concern of the state to control the ill health of its subjects or citizens. 13

HEALTH TARGETS IN EUROPE

The emphasis on the duty of the subject to pursue health was reflected in attempts to categorise illnesses which were “natural” and “man made”, i.e. caused by moral laxity. The evolution of this highly state-conserving public health into the social medicine of the 19th century followed the upheavals in political thinking and acts of the times. This social medicine (encapsulated in Rudolph Virchow’s famous dictum “Medicine is a social science, and politics nothing but medicine on a grand scale”) emerged as a heady mix of medical science and social reform. What Rosen’s story reveals is a strong European tradition of thinking about health polity from the 17th century, and earlier, to modern times. He reveals the historical construction of the contemporary stage on which the national and regional developments chronicled here are being acted out. Subsidiarity seems to be a key shibboleth in the lexicon of contemporary European politics and the idea is constantly invoked by our writers.The Oxford English Dictionary ascribes its origin to a 1931 papal encyclical: it sets out the principle that a central authority should have a subsidiary function, performing only those tasks which cannot be performed effectively at a more immediate or local level. Almost all those reporting on progress with health targeting in their respective countries comment on the tensions between transnational, national, regional, and municipal centres of power. While all governments have a centripetal tendency to accrete and retain control (often accompanied by earnest disavowals of any such tendency), the experience of health target implementation suggests that only a centrifugal impetus can succeed. People must have a sense of intimate ownership of the targets and their implementation at the local level. What then is the role and competence of the central state in matters of health policy? Almost all our writers here point to the relative success of health targeting at the subnational level and to the dangers of a national or supranational “top-down” and dirigiste approach. Karl Popper24 takes the following view of the European nation state: Nations … are theoretical constructs, and the theories in which they are constructed are wholly inadequate, and completely inapplicable to Europe. For the political theory of nationalism rests on the assumption that there are ethnic groups which at the same time are also linguistic groups, and which happen also to inhabit geographically unified and coherent regions with natural boundaries that are defensible from a military point of view – groups which are united by a common language, a common territory, a common history, a common culture, and a common fate. But no such regions exist – at least not in Europe … 14

EVIDENCE AND IMAGINATION

These grand “theoretical constructs” seem to have only limited relevance to health target implementation in Europe and perhaps only partial relevance to their adoption as policy. There are a number of change drivers that may challenge our assumptions about nationhood. Genomics will make possible not only a redefinition of diseases but also a journey of discovery into our hidden identities. Our genes will reveal new historical maps in which we may read how truly accidental and contingent are our places in this or that national location, ethnic enclave or mindset. The flags for which European men and women have so long been invited to die may be revealed as counterfeits of our true and richly complex hereditary identities. Solidarity would be given a new biological reality and we might be unshackled from our misleading histories to live in a better present. In instituting health targeting in Europe the most effective players appear to have been not central government bureaucracies but the German Laender, the Italian regions, provinces and communes, the Spanish autonomous communities, and so on. In terms of the United Nations’ designations of “Cities of Culture” or the World Health Organization’s “Healthy Cities”, it is the municipalities that count.We need this human scale because although national democracies may serve well the changing will of majorities, they do not serve well the often fixed needs and wishes of minorities. In terms of our healthy states and the illnesses that punctuate them, we are all members of suffering minorities. The new information technology will not only transform communication but make possible virtual realities – universities, pressure groups, communities, even hospitals. It is already possible to envisage a robotic hip replacement in Barcelona being closely assisted by an orthopaedic surgeon in his Berlin operating theatre. Most radically, by creating virtual communities of patients with like conditions, the health concerns of disparate health minorities can be given a truly powerful political voice. A new age of representative health polity dawns. The public health agenda in European history begins with 18th century mercantilism, progresses to socialism in the 19th century and to so-called market socialism and social democracy at the close of the 20th. Land was the measure of a country’s wealth until the early Middle Ages. Money became its measure around the 12th century, when short economic chains of barter ceased to serve the needs of an increasingly settled, socially differentiated and trading continent.25 As postmodern Europe matures over the coming years, health may now replace money as a more sensitive and human measure of our wealth. 15

HEALTH TARGETS IN EUROPE

What the essays written here seem to adumbrate is the emergence of a new public health, which gives life to a new politics for 21st century Europe. In this, the pursuit of health replaces the old political calculus of the pursuit of money and a new distributive agenda concerns itself with optimising everyone’s capacity for wellbeing. The writings of Sen, Anan, Peter, and others all point in the direction of this aspiration. This emerging European polity should be capable of extending the legacy of the public health concerns and achievements from the past, reconciling the paradoxes in our libertarian and collectivist values, and building on the contemporary insights of Amartya Sen and many other like-minded thinkers.We need to create a new politics that will realise the analysis made by Rudolph Virchow more than a century and a half ago – but with the crucial change of one italicised word.The politics of postmodern Europe could become “… nothing but health on a grand scale”.

Conclusion My fellow writers may be relieved to find that this introductory chapter has not attempted to reflect what they have written in the essays that follow, but rather to be a very personal reflection on them. They will now speak for themselves. I have written this “reflection” not to say what I know but to find out what I think. I should also confess that that is my usual modus operandi. The following salient themes have struck me as important. The first is the imperative of seeking a balance between the triad of evidence, moral values, and political will: all three must contribute to the coherence of targeting for health. The second is the recognition that, as in clinical medicine, the practice of public health is both a science and an art. The third is the emergence of a new health politics in Europe and the notion of a new distributive agenda in terms of health. I choose to give the last words here to Miquel Porta.26 He was writing specifically about the need for changes in food and environmental policies but I found his words had a deep resonance for so much of what is said and implied in what follows: … the efforts of public health, medicine and ecology will fail unless we capture the social imagination. Human health and ecological targets will hardly be achieved unless we seduce the hearts and minds of our fellow citizens, unless we shape the dreams of children, women and men … We say so little about the dreams, and so softly and out of tune – about the real dreams, the achievable utopias. 16

EVIDENCE AND IMAGINATION

References 1 Beck U. Risk Society. Cambridge: Polity Press, 1992. 2 van de Water HPA, van Herten LM. Bull’s Eye or Achilles’ Heel. Leiden, the Netherlands: TNO. 3 van de Water HPA, van Herten LM. Health Policies on Target? Leiden, the Netherlands: TNO. 4 van Herten LM. Health Targets: navigating in health policy. Amsterdam: TNO. 5 WHO. European Health for All. Series No. 6. Geneva: WHO. 6 Sontag S. Territorial Imperatives. Guardian, June 16, 2001. 7 Eliot TS. The love song of Alfred J Prufrock. Collected Poems 1909–1935. London: Faber, 1937. 8 Williams A. Applications in management. In: Teeling-Smith G, ed. Measuring Health: a practical approach. Chichester: Wiley, 1988. 9 Bronowski J. Science and Human Values. London: Pelican, 1958. 10 Crown J, Gunning-Schepers L. The challenge to public health advocacy. In: Marinker M, ed. Sense and Sensibility in Health Care. London: BMJ Books, 1996. 11 Illich I. Medical Nemesis. London: Boyars, 1974. 12 Peter F. Health equity and social justice. J Appl Philosophy 2000; 18(2):159–70. 13 Canguilhem G. On the Normal and the Pathological. New York: Zone Books, 1991. 14 McCormick J, Anderson D. Risk, Health and the Consumer. London: Social Affairs Unit, 1992. 15 Skrabanek P, McCormick J. Follies and Fallacies in Medicine. Whithorn: Tarragon Press, 1998. 16 Wilkinson RG. Income distribution and life expectancy. BMJ 1992;304:165–8. 17 Daniels N, Kennedy B, Kawachi I, et al. Justice is good for our health. Boston Review, 2000; February/March. 18 Pearce N. The ecological fallacy strikes back. J Epidemiol Community Health 2000;54:326–7. 19 Shaw M, Miles I. The social roots of statistical knowledge. In: Irvine J, Miles I, Evans J, eds. Demystifying Social Statistics. London: Pluto Press, 1979. 20 Armstrong D. The invention of infant mortality. Sociol Health Illness 1986;8(3):211–32. 21 Morgan G. Images of Organisation. London: Sage, 1986. 22 Hawthorn G, in Sen A. The Standard of Living. Cambridge: Cambridge University Press, 1987. 23 Rosen G. From Medical Police to Social Medicine. New York: Science History Publications, 1974. 24 Popper K. The Myth of the Framework. London: Routledge, 1994. 25 Elias N. The Civilising Process. London: Blackwell, 1994. 26 Porta M. Achievable Utopias. Departmental paper. Barcelona: IMIM UAB, 2001.

17

2: Historical perspectives on European health and policy LOES VAN HERTEN AND LOUISE J GUNNING-SCHEPERS

Developments in population health Since health targets are conceived as a means of translating health policy into positive developments in population health, we begin with population health. Current developments in health policy in general, and the development of health target setting in particular, are better understood in the light of the state of European population health over the last century. If one regards the progress of population health from the historical viewpoint, it is not difficult to identify the ageing of the population as one of the most salient trends of modern times. During the last century, industrialised countries have witnessed a dramatic increase in life expectancy: from 40 to 50 years at the beginning of the last century; from 70 to 80 in recent years.This increase in life expectancy results from an impressive reduction in mortality rates for the adult population and (following the second world war and the postwar baby boom) an even more impressive reduction in infant mortality. Consequently health policy is challenged by a large group of elderly persons with many calls on the healthcare services. Socioeconomic developments such as industrialisation, urbanisation, better hygiene, nutrition, housing, and increasing prosperity are believed to have laid a sound basis for the improvement in life expectancy. A difference of opinion exists about whether the contribution of medical science has been very relevant or only modest. Critics such as Illich and McKeown have pointed to the limited, and possibly even counterproductive, role of medicine.1,2 Others are much more positive and refer to the important contribution of sanitary movements, the development of vaccines, the discovery of 18

HISTORICAL PERSPECTIVES ON EUROPEAN HEALTH AND POLICY

antibiotics and other medicines. They point to increasing progress in the treatment of previously fatal conditions and to the proliferation of technological ingenuity.3 It is true, however, that there is also a reverse side to medical interventions. Consider, for instance, the antibiotic resistance of pathogenic micro-organisms. On the other hand, it is difficult to imagine how the impressive reduction in infant and maternal mortality could have been achieved without the introduction of prenatal care and medical technologies. The history of the development of population health is divided into four phases; a change from one phase to another is called an epidemiological transition.4–6 The epidemiological transitions in population health in Europe have occurred at a different pace in different countries. However, on the whole, because the causes of morbidity and mortality that underlie the transitions change in a similar way, all countries follow a similar path throughout their industrial development. In the first period, the phase of “pestilence and famine”, life expectancy was about 30 years. During this phase, infectious diseases such as cholera had a decimating effect. This phase gave way to a second phase of “receding pandemics”, with a life expectancy of about 50 years, when other causes of death started to replace the infectious diseases. This ushered in the third phase, that of “degenerative and manmade diseases”, when life expectancy increased to 70 years. In this phase, cardiovascular diseases, cancer, and accidents were the major causes of death. Since about 1970 a new pattern has been observed: that of “delayed degenerative diseases”. This contemporary phase is characterised by a further increase in life expectancy, primarily through a decrease in cardiovascular diseases and accidents. However, there has also been an increase in non-fatal diseases presumably related to the degenerative processes of ageing. Diseases such as dementia, arthritis, and osteoporosis play a major role in decreasing the quality of life and represent an increase in the burden of disease, although they are seldom the primary causes of death. Hence, the greying of populations seems to coincide with an increase in chronic diseases and disabilities. Consequently, we must question whether the additional years gained in life expectancy will be spent in good health or in a prolonged state of illness and dependency. Since about 1980 this question has formed the nucleus of a scientific debate on the relationship between the evolution of mortality and the evolution of morbidity. This has given rise to three theories: a pessimistic, an optimistic, and an in-between theory. 19

HEALTH TARGETS IN EUROPE

Gruenberg and Kramer consider it unavoidable that the burden of morbidity will continue to grow and they fear the so-called expansion of morbidity.7,8 Fries, on the other hand, has expressed the view that with modern medical interventions and preventive measures, it will be possible to postpone the onset of chronic illness and disability until the end of human life, thus causing a “compression” of morbidity and disability.9,10 The third theory refers to a dynamic equilibrium and argues that although increases in life expectancy will lead to more disease and disability, these will be less severe in the future, as future populations will generally become healthier.11 Many longitudinal and other studies have been undertaken to test these theories. So far, studies of trends in health expectancy, and the development of disabilities, have suggested that the mechanism of dynamic equilibrium seems to be working and an increasing number of publications even support the concept of the “compression” of morbidity to the end of life. Nonetheless, the absolute number of people with disabilities is likely to increase significantly.12 Although as a result of the long-standing struggle against premature mortality, populations in industrialised countries now enjoy longer lives but also experience relatively more chronic conditions and disabilities, this situation is not the same in underdeveloped regions which are still plagued by infectious diseases. In most European countries, the spotlight is now on the increase in chronic morbidity due to non-fatal diseases. However, even within Europe, great differences can be observed. In some parts of eastern Europe people are still living in the third epidemiological phase of transition; they are struggling with mortality due to cardiovascular diseases, cancer, and accidents.

Developments in health policy Following the Industrial Revolution, state welfare policies spread across Europe. Bismarck took some remarkable steps in Germany in the second half of the 18th century, initiating laws on social insurance that brought great benefit to all groups of the population. It guaranteed wage earners medical care, compensation for the loss of wages due to illness or accident, and pensions when they lost their earning capacity as a result of illness, accident or old age. These developments in Germany prompted other countries to develop their own health insurance and welfare policies.13 The second world war gave increased significance to the problem of social security. A clear example was the request by the British 20

HISTORICAL PERSPECTIVES ON EUROPEAN HEALTH AND POLICY

government to Sir William Beveridge to review existing national schemes of social insurance and to make recommendations.13 This resulted in the National Health Service, financed from general taxation. Both of these models (Bismarck and Beveridge) can be seen in Europe today, with the Bismarck model adopted in eastern and central Europe and the Beveridge model in southern and northern Europe.14 The Industrial Revolution and increased urbanisation stimulated the development of prevention policies. Diseases were associated with poor housing and working conditions and nutritional deficiencies. At the same time increasing knowledge of bacteriology in the second half of the 19th century made possible more specific measures, like vaccination. In several countries, for example in Germany and the UK, physicians who were actively concerned in social matters urged governments to take public health measures in order to prevent diseases. Their calls for action met a broad social response. As a consequence, measures were introduced to reduce the transmission of infections and to improve the general health status. With so much accomplished, the sanitary movement then became rather less visible in general policy making.15 Scientific progress in the 19th century laid the basis for subsequent developments in both public health and medical care. Important innovations such as vaccination, antiseptic treatment, antibiotics, and diagnostic devices contributed to the growth of healthcare systems and small scale facilities, which started as initiatives of charity organisations, and were transformed into modern clinics and big hospitals. Initially the healthcare system worked with only marginal control mechanisms. The establishment of professional groups with standards and codes signified the beginning of “quality assurance” within the medical profession, although this term was not in use at that time. After the second world war, developments in health care accelerated. Many new drugs and medical technologies became available. Universal coverage allowed for health needs to be expressed as demands for health services and this required policy makers to arrange for the necessary supply. In those years many of the national or regional health departments were primarily concerned with setting up building and training programmes to fulfil this increasing demand. It was an era of growth and the need for policy measures to ensure a good geographical spread of services and a system of quality assurance for this rapidly expanding field is reflected in the health policy textbooks and training courses of the time. 21

HEALTH TARGETS IN EUROPE

Planning was the term used most often and reflects a systematic approach which is both possible, and called for, in situations of controlled expansion. The outcomes aimed for were expressed in terms of beds per 1000 population, numbers of health professionals, their geographic spread, and numbers of individuals who have, or do not have, access to some of the fundamental prerequisites for health. Expanding levels of vaccination coverage, numbers of women receiving adequate and timely prenatal care, families on the lists of general practitioners (GPs), and households with piped water and bathrooms were the kind of indicators then used.15,16 In the late 1970s the expansion of services had reached its zenith and, in the eyes of many countries, had vastly overshot the mark. As healthcare costs continued to increase, not only in an absolute sense but also in terms of the proportion of gross domestic product (GDP) spent on health care, policy attention shifted from building infrastructures to reducing costs. Policy targets were more and more phrased in terms of reducing overall expenditure by controlling supply: examples include capping the budgets for hospitals; capitation fees for GPs; limiting the number of doctors trained and the number of hospital beds provided. Improving the efficiency of health service delivery became the aim and this involved extensive policy discussions between those favouring government planning and those wishing for more market forces to be introduced into the healthcare field. Governments, professionals, and scientists devoted considerable effort to developing procedures and methods that would bypass the limitations of financial constraints. Developments such as quality assurance, medical technology assessment, and managed care aimed to increase effectiveness and efficiency and provide “more value for the same money”. In some cases policy initiatives for “healthcare reforms” were developed, aimed primarily at adapting healthcare financing systems in order to build in incentives for efficiency.15,16 In the 1980s, a time when the focus of health policy was fixed on the cost side of healthcare services and on the need to cut costs, the World Health Organization (WHO), in concert with some national governments, drew attention to the populations’ health as the central issue in health policy.17,18 This idea, advocating a shift away from the mere planning of health services towards planning for better health, inspired many. According to the Lalonde concept for a new health policy model, better health depended on influencing the determinants of health. The importance of this concept was that it focused on the status of population health while linking it to the five 22

HISTORICAL PERSPECTIVES ON EUROPEAN HEALTH AND POLICY

main spheres of influence on health. At the same time the information necessary to demonstrate a link between the implementation of policy and the potential health gain in the populations became available. This ushered in an era in which population health was placed at the centre of policy making. Both national and supranational policy documents started to quantify the health status of populations and to translate policy priorities into health targets. All these health targets quantitatively indicated what level of population health should be attained and by when. Sometimes they seemed to set relatively arbitrary targets, using population measurements of the prevalence or incidence of diseases, or of risk factors, as indicators. The targets are described as arbitrary because demographic and epidemiological developments were not taken into account. In relation to such targets, the policy documents specified what measures would be required and by whom. The outcome measures would include, for example, infant mortality rates, prevalence of hypertension, deaths due to motor vehicle accidents, mortality rates due to coronary heart disease or lung cancer.16 Further, progress towards achieving such targets was often monitored and reported to Parliament. The effects of reduced mortality on the one hand and the baby boom generation on the other reinforce each other and result in a large group of old people, many of whom suffer from chronic diseases and disabilities. Nowadays, governments have to deal with an ageing population. The challenges for government are twofold. First, the policy aim has shifted from not only adding years to life but also adding life to years. Second, the increasing number of elderly has resulted in even longer waiting lists for healthcare services. Also, old-fashioned threats appear in new disguises. The large scale changes in lifestyle (sex, drugs, increased international travelling, large scale food production, worldwide export of animal fodder, improper use of antibiotics, etc.) and the ingenuity of micro-organisms will continue to cause surprises. This can already be seen in the cases of Legionnaire’s disease, AIDS, CJD, and multiple drug resistance in tuberculosis.

Developments in health target setting The use of health targets in health policy was inspired by the “management by objectives” approach used in the business world.The term “management by objectives” was first introduced in 1954 by Drucker19 and refers to efforts to identify the individual steps and targets necessary to achieve common goals.The underlying assumption 23

HEALTH TARGETS IN EUROPE

is that it is possible to specify common goals which, when identified as explicit targets, will result in more focused and efficient efforts. It can be seen as a cyclical process, which starts with the definition of strategic goals and is followed by background documentation and the identification of objectives. In the next phase the objectives are implemented and monitored. This evaluation then informs the redefinition of the objectives, which are then implemented, and so on. The pioneer of management by objectives for health was McGinnis, who established and guided the implementation of the “Objectives for the Nation” in the United States.20 McGinnis distinguished several types of objectives applicable to health policy. His comparisons of the various types of objectives, as seen from the perspectives of business and health, are reproduced in Table 2.1. In bringing the management by objectives approach to the health sector, an important idea was born: health systems could be evaluated in terms of output as population health gains. Put more simply, the output of health policy would be healthier people. Table 2.1

Application of the “management by objectives” concept20

Objective bases

Business applications

Health applications

Outcome Strategy Productivity Marketing

Profits Product type and mix Labour/capital mix Client attitudes and awareness Product improvement

Morbidity and mortality reduction Risk factors Scope of services Public/professional attitudes and awareness Surveillance, evaluation, and research

Innovation

The use of health targets at the beginning of the 1980s was also made possible by advances in the use of epidemiology for public health purposes. Since the identification of tobacco smoking as the principal cause of lung cancer in the early 1950s, other major risk factors for non-communicable diseases were identified. The evidence from epidemiology relating to the contribution and magnitude of risk factors in health was impressive. Later, epidemiologists began to explore the subtleties of confounding variables, misclassification, survivorship, and other such issues. The results of experimental and observational studies led to evidence-based preventive interventions and increased the direct impact of epidemiology on policy decisions. Today epidemiology remains the basic science of public health, because it continues to provide an improved understanding of the 24

HISTORICAL PERSPECTIVES ON EUROPEAN HEALTH AND POLICY

causes of disease, disability, and death. This makes it theoretically possible to identify populations at risk and attempt to prevent disease and improve their health.21–24 Increasingly, more specific epidemiological data on various health problems in various population groups were collected. With the introduction of targets, the need to monitor and evaluate consistency of action also increased.This monitoring of health gains then initiated country-specific and international comparative epidemiological research and surveillance. The development of the European Health for All database is just one such initiative. Such epidemiological research and surveillance made it possible to base health policy on scientific facts rather than on untested expert opinions.21–24

European Union Can health policy be considered a responsibility of the European Union? There is some basis for this responsibility in the health and safety measures included in the European Coal and Steel Treaty and in Euratom – the forerunners of the European Union. Since the founding of the Community, the legal framework within which the European Union may take action in the field of health has evolved considerably.The Treaty on the European Coal and Steel Community (1951) and the Euratom Treaty (1957) contained provisions for cooperation in the field of occupational health with regard to the industries specified. The 1956 Treaty of Rome, although it does not mention health specifically, includes some articles which enable the Commission to promote close cooperation on social matters, including those relating to social security, prevention of occupational accidents and diseases, and occupational hygiene. In 1977 and 1978 the European Commission took the first steps to coordinating policies in the field of health (i.e. economic aspects of care, such as drug supply; health promotion in relation to smoking and nutrition; and mutual help in the case of serious outbreaks of diseases, and disasters). The 1986 Single Europe Act required the Commission to maintain a high level of protection for its citizens in all its proposals concerning health, safety and environmental and consumer protection, as these related to the working of the single European market. The most significant provision in the field of health was introduced in the 1992 Treaty of Maastricht. Article 3(o) introduced a new objective, making “a contribution to attainment of a high level of health protection” applicable to all policies of the European Union. 25

HEALTH TARGETS IN EUROPE

Article 129 of the Treaty provides a framework for public health activities in pursuit of this objective: disease prevention and research, health information and education, and the incorporation of health protection requirements in communal policies.25 Just after the 1992 Treaty went into effect, the Commission published a communication on a framework for action in the field of public health. This report described current health status, trends, and challenges within member states. It stressed the importance of tackling the determinants of health and the underlying causes of disease and outlined criteria for deciding priorities for action. On the basis of the analysis presented in the 1993 communication, the Commission proposed eight public health action programmes. These incorporated and built on the pre-Maastricht programmes on cancer, AIDS, and drugs. These eight programmes are: ● ● ● ● ● ● ● ●

cancer (expired 2000) AIDS and other communicable diseases (expired 2000) health promotion, education, and training (expired 2000) prevention of drug dependence (expired 2000) health monitoring (expired 2001) pollution related diseases (expired 2001) rare diseases (will expire 2003) injury prevention (will expire 2003).

In addition to these programmes, work has also continued in other areas related to the 1993 framework. Examples include the establishment of a European network for the control and surveillance of communicable diseases and initiatives against smoking, including communications on the role of the European Union in combating tobacco consumption and the adoption of a common position on tobacco advertising. Agreement has also been reached on a strategy for the safety of blood donations, including a Commission proposal for Council recommendations on the suitability of blood and plasma donors and the testing of donors. A comprehensive review has been undertaken on non-ionising radiation. Other examples include reports on health status in the European Union and on BSE and reported cases of Creutzfeldt-Jakob disease. The Commission also presented reports on health requirements in relation to other policies and stimulated studies on the development of health priorities in health systems and surveys of public opinion on health services.25,26 In the 1997 Treaty of Amsterdam a new article on public health appeared. It expanded the legal basis for public health activities and 26

HISTORICAL PERSPECTIVES ON EUROPEAN HEALTH AND POLICY

reflected an evolving consensus on the importance of the European Union’s action in this field. Without denying the responsibilities of member states and/or assigning them to the Commission, the new treaty acknowledged a broader definition of public health and recognised a greater Community role. The new article includes community action in the fields of: ● ● ● ●

improving health preventing diseases obviating sources of danger to health ensuring that all EC policies protect health.25,26

In the 1998 communication on the development of public health policy, the Commission indicated what the main themes should be and identified three strands of action. 1.

2. 3.

Improving information on public health – through the development of a comprehensive community system for collecting, analysing and disseminating information, focusing on trends in health status and health determinants, and on developments in health systems. Reacting rapidly to threats to health – by means of community surveillance, early warning, and a rapid reaction capability. Tackling health determinants through health promotion and disease prevention – with a focus on lifestyle related determinants, socioeconomic determinants, and measures related to the environment.

These three strands of action would also enable the European Union to respond effectively to the challenges of the expected growth of the European Union and to health requirements inherent in its other policies. Moreover, in all three strands it is intended to undertake work in two “horizontal areas” of activity: the integration of health requirements in other community policies and the health impact of EU enlargement.27

World Health Organization In 1980 the WHO launched its global Health for All programme. The aim was to ensure that by the year 2000 all citizens of the world would attain a level of health permitting them to live socially and 27

HEALTH TARGETS IN EUROPE

economically productive lives.17 The combination of developments in epidemiology, the American approach to setting health objectives for the nation, and the Lalonde health field concept contributed to the production of 38 targets by the WHO European Region, as a specifically European take on the global Health for All strategy.28 These 38 targets were endorsed in 1984 and motivated policy makers to think more rationally about health policy, the use of targets as a tool for improving health, and the methods and structures required to bring about significant improvements in population health. The first two 1984 European WHO health targets were intended to reduce the differences in health between social groups and to enhance the quality of life. The following 10 health targets focused on outcomes, in terms of mortality and morbidity (i.e. reduction in chronic diseases, infectious diseases, cardiovascular diseases, cancer, accidents, mental disorders, and suicide) and in terms of improving the health of specific groups (handicapped, elderly, children, and women). In addition, there were targets relating to health determinants. Some of them related to the public health sector, examples being the targets for the promotion of healthy lifestyles. Other targets related to health risk were intended to achieve a healthy environment and required action from other sectors. A third subgroup of health determinant related targets focused on appropriate care.The final group was more conditional in nature and called attention to the need to develop country-specific Health for All policies.28 Each European country was expected to elaborate these 38 targets in its own way. To monitor progress the WHO in Europe proposed a large number of indicators and member states agreed to report every three years on their progress. To synthesise the data, the WHO in Europe established a Health for All database. In 1991 the Regional Office in Copenhagen revised the targets and the indicators; deadlines for targets were shifted to the year 2000, the health of children, women, and the elderly was addressed more explicitly, and a completely new target, “health and ethics”, was introduced.29 In May 1998, the WHO adopted a resolution in support of a new global policy, Health for All in the 21st Century, which now succeeds Health for All by the year 2000.30 This renewal of Health for All, concurrent with the 50th anniversary of the WHO and the appointment of a new director general, offered a unique opportunity for the organisation to reaffirm its purpose. In the new policy, the worldwide call for social justice is elaborated in key values, goals, objectives, and targets.The 10 global health targets are the most concrete endpoints to 28

HISTORICAL PERSPECTIVES ON EUROPEAN HEALTH AND POLICY

be pursued. They can be divided into three subgroups: four are health outcome targets, two are targets on determinants of health, and four are targets on health policies and sustainable health systems. Again, all member states are supposed to set their own targets within this framework, based on their specific needs and priorities. In September 1998 the European Region of the WHO also approved a renewed European Health for All policy, called 21 Targets for the 21st Century – a public health guide to the Health for All policy for the European Region.31 These 21 targets can be divided into six groups: two targets on equity in health through solidarity in action; three on better health for the 860 million people of the European Region; four on prevention and control of disease and injury; five on multisectoral strategies for creating sustainable health; four on an outcome oriented health sector; and three on policies and mechanisms for managing change.

European landscape The 38 health targets formulated by the European Office of the WHO have had a marked influence on the thought processes underlying health policy developments. Most European countries made serious efforts to adapt them to their own situations but there is not one European country that has formally incorporated the full scope of that strategy into its health policy. After some initial enthusiasm, most of the countries lost interest in health targets. Many experts criticised the targets as being too ambitious and based on political will rather than on scientific (especially epidemiological) evidence. Another reason for the flagging interest might have been the length of time it took for the idea to filter through the political system.25 However, some European countries have formulated some health targets and although others may not have set targets, they have all formulated some general priorities, goals or objectives in the form of a related but less specific approach. In the countries which have formally adopted health targets, the degree of elaboration, the focus of the targets, and their practical implementation vary considerably. The core targets in most countries are similar in concern (equity, health promotion, etc.) but there is great variation in the number of health targets identified, in their focus on public health as distinct from health care, and in the actors involved.25 Other differences between countries reflect the differences in their regimes. Most countries have national health targets, some have both 29

HEALTH TARGETS IN EUROPE

national and regional health targets, and others have only regional targets. The autonomous responsibility for health policy assigned to the various levels of regional and local government defines the scope of the central government’s freedom to make national decisions about health. In a federal state, such as Switzerland, the national government simply does not have the right to define national health targets.25 The terms used in the policy documents of different countries, to define goals, objectives, and targets, vary considerably. In general, the process of targeting was conceived as a step by step approach, each taken with increasing specificity. Targeting starts with principles and values and proceeds by specifying objectives, goals, qualitative and quantitative targets, elaborated to the level of defined indicators for monitoring progress. This step by step approach was seldom adopted in European countries. Sometimes the wording of what was called a target was so general that it could more accurately be classified as a broad goal. As a rule, health targets were formulated in qualitative terms. The practical elaboration of targets – as, for example, happened in England – was the exception.25 The relatively small number of quantitative targets probably reflects the fact that most countries consider health targets a source of inspiration rather than a management or technical tool. This inspirational aspect is also reflected in the observation that many targets focus on rather broad areas such as equity, quality of life, and promotion of health. Health targets have also been employed as technical tools for policy making, in order to achieve an optimal balance between the allocation of available resources and its effect (health gain): an example is the health insurance targets in Germany. In other locations, for example in Catalonia, health targets are promoted as a management tool.25 In all countries with health targets, governmental authorities took the initiative in setting the targets, usually after consultation with professional and/or lay groups. In spite of the advantages of such governmental authority, there is also a potential risk when health targeting becomes highly dependent on the political preferences of the government in power. For example, in England an incoming administration reduced the number of national health targets from five to four and changed the emphasis: a change in government entailed a change in the emphasis and content of targeting. Although such changes are justifiable from a political point of view, they may compromise consistency, continuity, and progress. It takes several 30

HISTORICAL PERSPECTIVES ON EUROPEAN HEALTH AND POLICY

years to get health targeting going and long-term efforts are usually required in order to see a return on the investment. It would therefore be helpful if health targets were to have a broad social basis beyond government, with stronger anchors in the professional groups and the general public. The experiment taking place in Germany, where health insurers are trying to use health targets to increase the quality and efficiency of care, is an interesting one. Such an approach brings health targets much closer to the functioning of an actual healthcare system than has been possible, or in evidence, in so many governmental health policy documents.25 Ideally, setting health targets should be based on a broad insight into the nature of population health. Further, monitoring progress toward the targets should be inherent in the plans for target setting. The adoption of health targets constitutes a major challenge to health information systems. Health targets increase, and help to define, the need for health information. Most European countries have extended or improved their health information and monitoring systems in response to the introduction of a health targeting approach. One of the consequences implicit in this approach is the need for an overview of developments in population health – not fragments but one complete overall picture. Several countries, for example Finland, France, and the Netherlands, have started to produce a series of comprehensive national health reports, combining data from different sources in a way that is well structured and understandable to policy makers. This represents an important step forward.25

Conclusion In most European countries there have been marked similarities in the development of health policy and the concern for population health. Because hitherto the European Union treaties and policies focused on the internal market, the influence of the Union on health matters has been limited. However, it can now be expected that its influence will increase in the years to come. The influence of the WHO’s Health for All policy has obviously been great, especially in the policies oriented to public health. In the past any connection with healthcare policy was often missing and the use of health targets was diverse. Most countries used health targets as political tools. Only in a few instances, in the UK and some Spanish regions for example, has health targeting moved beyond policy to practice. Now, at last, in most other European countries the idea of health targeting is gaining 31

HEALTH TARGETS IN EUROPE

political support, an important precondition for further development. Despite this political support, health targeting still needs further development at both the policy and the practical levels. Why health targets? An answer is given here in the words of Peter Drucker, the pioneer of management by objectives. In 1954 he wrote19: Targets are not a railroad timetable. They can be compared to the compass bearing by which a ship navigates.The compass bearing itself is firm, pointing in a straight line toward the desired port. But in actual navigation the ship will veer off its course for many miles to avoid a storm. She will slow down to a walk in a fog and heave to altogether in a hurricane. She may even change destination in mid-ocean and set a new compass bearing toward a new port – perhaps because war has broken out, perhaps only because her cargo has been sold in mid-passage. Still, four fifths of all voyages end in the intended port at the originally scheduled time. And without a compass bearing, the ship would neither be able to find the port nor be able to estimate the time it will take to get there.

References 1 Illich I. Medical Nemesis – the expropriation of health. London: Marion Boyars, 1975. 2 McKeown THF. The Role of Medicine; dream, mirage or nemesis? Oxford: Blackwell, 1982. 3 Mackenbach JP. Mortality and Medical Care. Rotterdam: Erasmus University, 1988. 4 Omran AR. The epidemiologic transition: a theory of population change. Milbank Quart 1971;49:509–38. 5 Olshansky SJ, Ault B. The fourth stage of the epidemiological transition: the age of delayed degenerative diseases. Milbank Quart 1986;64:355–91. 6 Mackenbach JP. De veren van Icarus: over de achtergronden van twee eeuwen epidemiologische transitie in Nederland (The feather of Icarus: on the backgrounds of two centuries of epidemiological transitions in the Netherlands). Utrecht: Bunge, 1992. 7 Gruenberg EM. The failures of success. Milbank Quart 1977;55:3–24. 8 Kramer M. The rising pandemic of mental disorders and associated diseases and disabilities. Acta Psychiatr Scand 1980;62:382–97. 9 Fries JF. Aging, natural death and the compression of morbidity. N Engl J Med 1980;303:130–5. 10 Fries JF.The compression of morbidity. Milbank Quart 1983;61:397–419. 11 Manton KG. Changing concepts of morbidity and mortality in the elderly population. Milbank Quart 1982;60:183–224. 12 Robine JM, Mathers CD, eds. Health Expectancies at the Dawn of the Third Millennium. Montpellier: INSERM, in press. 13 Sigerist HE. From Bismarck to Beveridge: developments and trends in social security legislation, 1943. J Public Health Policy 1999;20:474–96. 32

HISTORICAL PERSPECTIVES ON EUROPEAN HEALTH AND POLICY

14 Schrivers AJP, ed. Een kathedraal van zorg. Een inleiding over het functioneren van de gezondheidszorg (A cathedral of health care services: an introduction in the functioning of the health care services). Maarssen: Elsevier, 2001. 15 van der Maas PJ, Mackenbach JP. Volksgezondheid en gezondheidszorg (Public health and health care). Utrecht: Bunge, 1995. 16 Gunning-Schepers LJ, van Herten LM. Targets in health policy. Eur J Public Health 2000;10:2–6. 17 WHO. Global Strategy for Health for All by the Year 2000. Health for All series no. 3. Geneva: WHO, 1981. 18 Lalonde M. A New Perspective on the Health of Canadians: a working document. Ottawa: Ministry of National Health and Welfare, 1974. 19 Drucker PF. The Practice of Management. New York/Evanston: Harper and Row, 1954. 20 McGinnis JM. Targeting progress in health. Public Health Rep 1985;97(4):295–307. 21 Robbins A. Public health in the next decade. J Public Health Policy 1985;6(4):440–6. 22 Kuller LH. Epidemiology and health policy. Am J Epidemiol 1988;127(1):2–16. 23 Susser M, Susser E. Choosing a future for epidemiology, I: eras and paradigms. Am J Public Health 1996;86(5):668–73. 24 Pearce N. Traditional epidemiology, modern epidemiology, and public health. Am J Public Health 1996;86(5):678–83. 25 van de Water HPA, van Herten LM. Health Policies on Target? Review of health target and priority setting in 18 European countries. Leiden: TNO Prevention and Health, 1998. 26 Belcher PJ. The Role of the European Union in Health Care. Zoetermeer: Council for Health and Social Service, 1999. 27 Holland W, Mossialos E, eds. Public Health Policies in the European Union. Hampshire: Ashgate, 1999. 28 WHO Regional Office for Europe. Targets for Health for All: targets in support of the European strategy for Health for All. Copenhagen: WHO Regional Office for Europe, 1985. 29 WHO Regional Office for Europe. Health for All Targets: the health policy for Europe. Copenhagen: WHO Regional Office for Europe, 1993. 30 WHO. Health for All in the 21st Century. Geneva: WHO, 1998. 31 WHO Regional Office for Europe. Health 21: the Health for All policy for the WHO European Region. 21 targets for the 21st century. Copenhagen: WHO Regional Office for Europe, 1998.

33

3: For and against health targets JAMES MCCORMICK AND NAOMI J FULOP

17 April 2001 Dear Naomi, Health is a difficult concept. For me it is “coping with the slings and arrows of outrageous fortune” rather than the World Health Organization’s aspiration or the doctor’s notion of absence of disease. I think that what these targets set out to do is to diminish morbidity and premature mortality. In order to achieve these objectives it is necessary to understand cause and to have a method of modifying that cause. Are there then ways in which we may aspire to reduce the burdens of morbidity and premature death? Unfortunately our knowledge of the cause of most diseases that are responsible for substantial morbidity and premature mortality is either imperfect or non-existent. I am thinking particularly of coronary heart disease and most cancers. The ethical imperative Almost 30 years ago Archie Cochrane and Walter Holland wrote: We believe that there is an ethical difference between everyday medical practice and screening. If a patient asks a medical practitioner for help, the doctor does the best he can. He is not responsible for defects in medical knowledge. If, however, the practitioner initiates screening procedures he is in a very different situation. He should, in our view, have conclusive evidence that screening can alter the natural history of disease in a significant proportion of those screened.1

This ethical imperative has never been disputed although it has sometimes ignored. Furthermore, I have argued that the responsibility for conclusive evidence should apply to the whole field of public health.2 If a doctor advises or treats a patient in ways that are ineffective or harmful, only 34

FOR AND AGAINST HEALTH TARGETS

that patient suffers. If a public health policy is ineffective or harmful, whole populations run the risk of diminished health. It follows that the degree of certainty should be much greater in matters of public health than in the conduct of the ordinary clinical consultation. Coronary heart disease The diseases we best understand are the infections and I have no difficulty in accepting as a legitimate target high levels of childhood immunisation. On the other hand it is widely believed that coronary heart disease is preventable and to this end the public have been bombarded with advice and many have been screened for risk markers, although “conclusive evidence” of the kind demanded by Cochrane and Holland is almost entirely lacking. The problem with coronary heart disease is our ignorance. Over 300 risk markers have now been described. This is a monument to industry but a reflection of ignorance. I use the term “risk marker” because although every epidemiologist knows that the term “risk factor” describes an association and nothing more, risk factors are too readily assumed to have causal relationships with disease. True, cigarette smoking is strongly associated with relatively young men’s myocardial infarctions, probably mediated through alterations in fibrinogen. But this effect disappears in older men and is not so apparent in women.3 One of the problems is an attempt to simplify the complex. As Henry Mencken observed: “Every complex problem has a solution which is simple, direct and wrong”. To regard coronary heart disease as a single entity is an example. Death from myocardial infarction at a relatively young age, usually a clotting phenomenon in the absence of a collateral circulation, is not the same entity as stable angina of exertion in an elderly woman. Nor are the arterial changes of familial hypercholesterolaemia or in rabbits fed high fat diets the same as those which seem to be an inevitable consequence of ageing.4 Cholesterol levels are a good risk marker and satisfy most of Bradford Hill’s criteria for causality. It may be, however, that these levels are themselves a marker for something else as yet not understood. It is fascinating that in the 4S study the good effects of statins were just as great in those whose cholesterol was 5 mmol as in those whose level was 8 mmol.5 We are still bombarded with advice about diet to prevent coronary disease, much of this concerned with lowering cholesterol.Yet even stringent diets have very little effect on cholesterol; cholesterol levels are largely genetically determined. 35

HEALTH TARGETS IN EUROPE

No randomised controlled trial has shown that what you eat alters the incidence of myocardial infarction. I am tempted to go on and on about the flaws in the “cholesterol as cause” thesis but will for the moment desist.6 The point I wanted to make is that in the present state of our ignorance dietary advice is unethical. Yes, I am an “abominable no-man” and am happy to be so.7 Cancers Our knowledge of the cause of common cancers, with the exception of lung cancer, is extremely poor. Genes are known to be important in a minority of instances but otherwise, with the possible exception of sunlight and rodent ulcers and maybe malignant melanoma, we do not know enough to have an ethically defensible strategy. As a result our hopes have been invested in screening.The only certainly effective forms of screening are those which are concerned with rare disorders which are detectable in neonates. Screening for phenylketonuria and congenital hypothyroidism are justified because although their prior probability is low, the burden of false positives is small and the benefits of early diagnosis immense. In the United Kingdom and elsewhere there are national schemes to screen for breast cancer and cancer of the uterine cervix. Both of these are questionable practices and may do more harm than good. Turning first to breast cancer, it is probably a priori unlikely to be effective because by the time it is detectable the tumour has undergone many cell divisions and if metastasis is to happen it will already have done so.8 There is also disturbing recent evidence that it is ineffective.9–12 Little attention has been focused on the subjective nature of the interpretation of mammographs although it has been shown that there may be widespread disagreement even between the experienced.13 Also until recently there has been virtually no attention paid to the ethical imperative of obtaining informed consent.14 I was delighted to read the other day that a recent report from the UK National Screening Committee (for which Dr Muir Gray is largely responsible) stresses the importance of informed choice and the right of refusal.15 It is now more than 10 years since I suggested that screening for cancer of the cervix was a questionable practice and nothing has happened in the intervening period to make me alter that view.16 Angela Raffle’s reports of her experience in Avon demonstrate that 36

FOR AND AGAINST HEALTH TARGETS

the harms exceed the benefits.17 I would not wish to deny that regular smears will allow useful early diagnosis and prevent premature mortality in a small number of women, but the possibility of harm is so great that it outweighs the possibility of benefit. It may be that better tests for the presence of human papilloma virus, especially HPV16, will allow the identification of high risk groups in which routine smears may be effective. That day has not yet come. Behaviour There are also the misfortunes which result from behaviour, smoking, drinking to excess, driving too fast, and suicide. The problem is to discover a strategy for change. Our behaviours are culturally determined by families, peers, and the wider society. The considerable success in relation to smoking has been achieved by making smoking deviant, even sinful, rather than normative. Drunken driving is condemned in many societies and has allowed the instigation of punitive damages. Otherwise, drinking to excess has been medicalised to little purpose. Despite speed restrictions, dangerous driving, especially by the relatively young, persists and shows little sign of abatement. There are other misfortunes which are benevolently regarded, skiing accidents, accidents on the football field, yachting misadventure, even motor racing tragedies. The problem with harmful behaviours is the lack of effective strategies for change. It is all very well to set targets for a reduction in suicide or in excessive drinking but there are no proven strategies for achieving such goals. My view, in brief, is that there are very few targets for health which are both ethically defensible and reasonably achievable. I look forward to hearing from you. With best wishes, Yours, James References 1 Cochrane AL, Holland WW. Validation of screening procedures. Br Med Bull 1971;21:3–8. 2 McCormick JS. Medical hubris and the public health: the ethical dimension. J Clin Epidemiol 1996;49:619–21. 3 Seltzer CC. Framingham Study data and “established wisdom” about cigarette smoking and coronary heart disease. J Clin Epidemiol 1989;42:743–50. 4 Stehbens WE. The Lipid Hypothesis of Atherogenesis. Austin, Texas: Medical Intelligence Unit, RG Landes Company, 1993. 37

HEALTH TARGETS IN EUROPE

5 Scandinavian Simvastatin Survival Study Group. Baseline serum cholesterol and treatment effect in the Scandinavian simvastatin survival study(4S). Lancet 1995;345:1274–5. 6 Ravnskov U. The Cholesterol Myths. Washington DC: New Trends, 2000. 7 McCormick JS. The abominable no-men: a cautionary tale. Perspectives Biol Med 1990;33(2):187–9. 8 Skrabanek P. False premises and false promises of breast cancer screening. Lancet 1985;ii:316–20. 9 Sjonell G, Stahle L. Halsokontroller med mammografi minskar inte dodlighhet i brostcancer. Lakartidningen 1999;96:904–13. 10 Gotzsche PC, Olsen O. Is screening for breast cancer with mammography justifiable? Lancet 2000;355:129–33. 11 News. Mammography is no better than physical examination, study shows. BMJ 2000;321:785. 12 Mittra I, Baum M, Thornton H, Houghton J. Is clinical breast examination an acceptable alternative to mammographic screening? BMJ 2000;321:1071–3. 13 Elmore JG, Lee CH, Wells CK, Howard DH, Feinstein AR. Variability in radiologists’ interpretation of mammograms. N Engl J Med 1994; 331:1493–9. 14 Skrabanek P. Why is preventive medicine exempted from ethical constraints? J Med Ethics 1990;16:187–90. 15 News.Warn the public of screening limitations, staff told. BMJ 2000;321:914. 16 McCormick JS. Cervical smears: a questionable practice? Lancet 1989;ii:207–9. 17 Raffle AE, Aiden B, Mackenzie EFD. Detection rates for abnormal cervical smears: what are we screening for? Lancet 1995;345:1469–73.

4 May 2001 Dear James, Thank you very much for your most stimulating letter. The main thrust of your argument, as I understand it, is that health targets are broadly unethical because we do not understand the causes of most diseases sufficiently and, even where we do, we do not have methods to modify those causes. I do not want to dispute your argument that basing health targets or broader public health policy on insufficient or faulty evidence is unethical. However, I believe that your argument against health targets is too narrowly utilitarian in its focus purely on “evidence”. It parallels the current UK government’s focus on “what matters is what works”1 that frequently appears to downplay the importance of drawing on a broader, coherent philosophy. Implementing policies solely on the basis that they have been shown to “work” without regard to the 38

FOR AND AGAINST HEALTH TARGETS

values underlying these policies leads to a sterile society. As Giddens has argued, government has an important “civilising” role – “government reflects widely held norms and values, but can help shape them, in the educational system and elsewhere”.2 Thus, I believe, there are more fundamental reasons to have health targets. As argued elsewhere in this book (see Chapter 13), the use of health targets by governments implies that the state has a concern for the health of its population. So, first, I wish to dispute your interpretation of what health targets set out to do. You say targets set out “to diminish morbidity and premature mortality”. However, health targets may have a broader purpose. For example, the most recent health strategy for England aims to “improve the health of everyone and the health of the worst off in particular” (original emphases).3 This, at least in theory, reflects the value system of the government which published this document, i.e. that inequalities in health should be reduced and that the government has a role in achieving this. Another government might aim to improve the health of everyone but happily live with health inequalities. Health targets can and should have a much wider aim to provide an emphasis on broader health issues than just service provision. This is important precisely because it highlights that the causes of disease are complex and multifactorial and include economic, social, and cultural factors. Just because these are difficult to set targets for doesn’t mean that we shouldn’t set goals to address them. Targets act as an important marker of a government’s priorities and provide inspiration and motivation.4 Finally, good practice in management can, and should, be applied to public health and health policy just as in other sectors. Setting targets for health draws on the concept of “management by objectives” originally developed by Peter Drucker5 in the 1950s.6 This concept builds on the assumption that once common goals are agreed they can be more efficiently achieved when explicitly identified in targets. Agreeing common goals is a vital stage in setting targets. In itself this is important as the process involves prioritisation. As we know, if everything is a priority then nothing is. In England, recent governments have placed priority on the main contributors to mortality and morbidity rates, namely coronary disease, stroke, cancer, mental health, and accidents.Whilst these have been criticised for being too disease based,7 the policy of setting priorities and targets is generally supported by those who are involved in implementing them.8 39

HEALTH TARGETS IN EUROPE

In summary, then, my view is that there is a strong ethical and managerial case for setting health targets. I look forward to hearing from you. Naomi References 1 2 3 4 5 6 7 8

Blair T. The Third Way: new politics for a new century. London: Fabian Society, 1998. Giddens A. The Third Way. Cambridge: Polity Press, 1998. Department of Health. Saving Lives: our healthier nation. London: Stationery Office, 1999. Nutbeam D, Wise M. Planning for Health for All: international experience in setting health goals and targets. Health Promotion Int 1996;11(3):219–26. Drucker P. The Practice of Management. New York: Harper and Row, 1954. van Herten LM, Gunning-Schepers LJ. Targets as a tool in health policy. Part I: lessons learned. Health Policy 2000;53:1–11. Fulop N, Hunter DJ. Saving lives or sustaining the public’s health? BMJ 1999;319:139–40. Department of Health. The Health of the Nation – a policy assessed. London: Stationery Office, 1998.

9 May 2001 Dear Naomi, Our differences seem to be mainly of a philosophical nature. Your main criticism of my earlier letter is that its focus is too narrow, rather than its arguments are seriously flawed. I have problems with pious aspiration. I do not believe that the World Health Organization’s goal of “Health for All by 2000” has been useful or valuable, particularly as the health of most of the world’s population has got worse in the years since the goal was first promulgated. By the same token I absolutely agree that, were it possible, reducing social inequality would make a greater contribution to health in Europe than anything else.Yet since the Black Report, despite aspiration things have got worse rather than better. You say that “targets act as an important marker of a government’s priorities and provide inspiration and motivation”. I can adduce no evidence to support this assertion. I find it deeply worrying that despite the promises of government to alleviate poverty, poverty which is much more than lack of money, nothing has been achieved in the United Kingdom or in the Republic of Ireland. Democracies may be bad places for minorities to live. The 40

FOR AND AGAINST HEALTH TARGETS

poor are a minority, albeit a large one, and their needs can be safely ignored by those who hold political power. (I must immediately confess the narrowness of my perspective which includes massive ignorance of the rest of Europe.) I find nothing intrinsically wrong with setting targets and goals but unless these targets are accompanied by strategies to achieve them they may in the long term, because of repeated failure, do more harm than good. Being in favour of something is of itself inadequate. I understand your hierarchy of goals followed by targets and am happy that we should discuss goals as a first step. My problem is that unless there are strategies for achieving targets which derive from goals nothing other than aspiration results. Scepticism is the scalpel which frees accessible truth from the dead tissue of unfounded belief and wishful thinking.1 It must be clear that I am a sceptic and happy so to be but I should make it clear that scepticism is not a synonym for cynicism and cynic I am not. Please give me some evidence, if you can, that the setting of goals has led to their being achieved. I think that it may be possible to set worthwhile and achievable targets; an example would be to reduce the burden of unwanted pregnancy.The Netherlands have shown the way.There would of course be many obstacles in following their lead, not least cultural constraints which would be very evident in the Republic and I suspect elsewhere. I would be happy if collectively we could identify targets which might be achievable, although the number might be small. I would be unhappy if we were to reiterate aspirations without a methodology to make their achievement a real possibility. With best wishes, James References 1

Skrabanek P, McCormick JS. Follies and Fallacies in Medicine, 3rd ed. Whithorn: Tarragon Press, 1998.

18 June 2001 Dear James, Thank you very much for your reply. I think our views may be converging! I completely agree that there is no point in setting targets unless strategies are developed to achieve them. 41

HEALTH TARGETS IN EUROPE

In your first letter you set out the case against screening for diseases or risk factors where there is insufficient research evidence to support it. Of course, in the case of, say, cholesterol, it is difficult to disagree with you. However, the case for screening for breast cancer is much more highly contested. It is possible to reduce mortality by reducing time to diagnosis which can be facilitated by screening and, given that the UK has the highest mortality rates for breast cancer in Europe, setting targets to achieve this seems sensible. It appears that the development of the national screening programme in the UK has at least contributed to the reduction in mortality.1 You also refer to attempts to reduce cigarette smoking to reduce rates of lung cancer and CHD. This is a case where we do have evidence that some strategies work. The report of the Chief Economist of the Department of Health indicated that controls on tobacco advertising result in reductions in smoking.2 Your letters also raise the issue of what we can agree may be defined as “evidence”. In your first letter, you state “no randomised controlled trial has shown that what you eat alters the incidence of myocardial infarction”. In your last letter, you exhort me to “provide some evidence, if you can, that the setting of goals has led to them being achieved”. As you know, it is not possible to carry out a randomised controlled trial on the relationship between what you eat and the incidence of myocardial infarction (although it is possible to provide good evidence from rigorous observational studies, for example the Harvard nursing study). Similarly, it is not possible, nor appropriate, to carry out a randomised controlled trial to test the outcomes of setting health targets. To ask whether the process of setting targets has led to them being achieved is not really addressing the right question, given the difficulties of attributing the intervention to the outcome. Complex policy interventions need to be evaluated in a different way, at least in part because by focusing on inputs and outputs, the experimental approach fails to take into account the underlying processes and the social context within which a change (for example setting targets) is introduced. In order to study these, the case study method can be adopted – comparative case studies (or “natural experiments”) can be particularly useful,3 although dependent on the policy not being universally introduced. Generalisations can then be made through the development of theory, rather than through aggregation.4 42

FOR AND AGAINST HEALTH TARGETS

A study of the implementation of a national health strategy in England, which included targets, could not compare areas where targets had been introduced with those where they had not, because the policy was universal. However, it found that those working in the field believed the strategy had led to an increase in prevention activity and enabled health promotion efforts to be prioritised and coordinated, although it indicated only a limited effect on patterns of resource allocation.5 This study, along with others,6 has identified the necessary components for developing public health strategies and setting targets. I hope we can begin to agree that targets can be useful and debate how they can be used as an important element of health policy. With best wishes, Naomi References 1

2 3 4 5 6

Blanks RG, Moss SM, McGahan CE, Quinn MJ, Babb PJ. Effect of NHS breast screening programme on mortality from breast cancer in England and Wales,1990–98: comparison of observed with predicted mortality. BMJ 2000;321:665–9. Economics and Operation Research Division, Department of Health.The effect of tobacco advertising on tobacco consumption: a discussion document reviewing the evidence. London: Department of Health, 1992. Harrison S. Policy analysis. In: Fulop N, et al., eds. Studying the organisation and delivery of health services. Research methods. London: Routledge, 2001. Pawson R, Tilley N. Realistic evaluation. London: Sage, 1998. Fulop N, Elston J, Hensher M, McKee M, Walters R. Lessons for health strategies in Europe: the evaluation of a national health strategy in England. Eur J Public Health 2000;10:11–17. van Herten LM, Gunning-Schepers LJ. Targets as a tool in health policy. Part 2: guidelines for applications. Health Policy 2000;53:13–23.

12 July 2001 Dear Naomi, I am delighted that you agree that there is no point in setting targets unless strategies are developed to achieve them. I hope that we may build on this agreement. You specifically raise the issue of breast cancer screening.Yes, some would maintain that there is good evidence of benefit, whereas others remain unconvinced. To set a target for universal screening by mammography while this uncertainty persists is both unwise and unethical. 43

HEALTH TARGETS IN EUROPE

More importantly, there is a tension between us, regarding evidence. I have taken a purist, maybe pompous, stand on the need for good evidence in order to justify setting targets and developing strategies for achieving them. On the other hand, you say that “to ask whether the process of setting targets has led to them being achieved is not really addressing the right question, given the difficulties of attributing outcome to intervention”. I should make it clear that while I subscribe to the value of the randomised controlled trial, I do not regard it as the only source of admissible evidence. In some instances things are self-evidently good. In my professional lifetime nothing has made a greater contribution to health and well-being than elective surgery for such things as cataracts and osteoarthritic joints. There are problems in relation to comparative case studies which have to do with hidden confounding variables. For example, a recent study in Norfolk demonstrated that high levels of plasma ascorbic acid were associated with reduced mortality.1 To impute causality or to argue that we should eat more oranges implies that the only difference between those with high and low levels of ascorbic acid was their dietary intake. The authors took account of many variables including such things as smoking and lipid levels but failed to take account of poverty. Poverty is an important and, on the whole, neglected risk marker for both coronary and total mortality. I would hazard a guess that the poor ate a less ascorbic rich diet than the wellto-do, partly because of cost and partly because of cultural habit. I would also guess that their higher mortality was a result of poverty rather than eschewing vegetables. Health promotion worries me because in many instances it takes health away. David Mant reported that in the British Family Heart Study almost four out of every five individuals were deemed unhealthy.2 Some were smokers but others were categorised as unhealthy on the basis of such dubious criteria as a body mass index greater than 25 or a total cholesterol greater than 5 mmol. As David Metcalfe remarked, the job of general practice (and indeed of all medicine) is to give health back to people. A professor of health promotion has written: Public health guidelines, as opposed to guidelines for specific individual management, are all broadly in agreement on advice to eat a balanced diet, take more exercise, and reduce the relative fat intake in favour of fruit and vegetables. While these may be argued as vague or aspirational by some, it is unlikely from known evidence that qualitative advice of this kind could translate into a nutritional catastrophe.3 44

FOR AND AGAINST HEALTH TARGETS

This unexceptionable statement ignores the extent to which inappropriate concern about diet has diminished people’s enjoyment of food, added to maternal anxiety and possibly encouraged eating disorders. I accept that health targets may act as a medium for health education. A government which introduces laws to restrict tobacco advertising and sale to the young is making a powerful statement, although I am not sure that it makes a contribution to reducing smoking. Nonetheless I cannot justify the promulgation of health targets as statements of concern unless they are accompanied by strategies for change. Our societies are characterised by inequity of a gross kind. As you have said, the reduction of such inequity would be a major contribution to improved health and I would accept it as a legitimate target although uncertain of the most effective strategies to achieve the goal. At a more mundane level in the context of equity of access to health services, I would happily support a health target to make relatively speedy access to elective surgery available to all. It is tragic to observe the unnecessary suffering of those condemned to protracted time on waiting lists. It is also ethically indefensible that speedy access, while denied to the poor, is available to the rich, which is the case in the Republic. I remain unconvinced that there is a utility in setting health targets, which are nothing more than declarations of interest or aspiration. I also remain convinced that it is possible to identify relatively specific targets for which there are strategies that offer the prospect of successful achievement. I suspect that the number of these is small but nonetheless their achievement would make a worthwhile difference. I have enjoyed this dialogue and in the process we have moved closer together but still remain apart, which is as it should be. With best wishes, Yours, James References 1 2 3

Khaw K-T, Bingham S, Welch A, et al. Relation between plasma ascorbic acid and mortality in men and women in EPIC-Norfolk prospective study: a prospective population study. Lancet 2001;357:657–63. Mant D. Health checks–time to check out? Brit J Gen Pract 1994;44:51–2. Kelleher C. Health Promotion: shades of Lewis Carroll. J Epidemiol Community Health 1995;49:1–4. 45

HEALTH TARGETS IN EUROPE

20 July 2001 Dear James, Thank you very much for your latest letter. We do indeed have very different perspectives on the nature of evidence and the types of research needed to evaluate different kinds of interventions. Research methods required to evaluate clinical interventions or relationships between risk factors and outcomes are not necessarily the same as those required to evaluate policy developments. (Although I would argue that surgical interventions, such as for cataracts and joint replacements as you mention, require the same level of evidence as other clinical interventions.) I was suggesting in my previous letter that, since it is not possible to attribute health improvements to the setting of targets, case studies can be used to evaluate policy developments, such as target setting, in order to study the underlying social processes. (Although studying the underlying social processes in the evaluation of clinical interventions or the relationship between, say, dietary factors and health is also very important, not least in order to understand the role of poverty which, as you quite rightly assert, is an important risk factor.) Your concern about inequities is something we can agree on. While you argue that the reduction of inequity is a legitimate target, you question whether there are effective strategies to achieve this.You cite the issue of improving access to health services; while I agree that this is a fairly narrow way to approach the overall target, a target to reduce inequities in access to, say, effective elective surgery could make a contribution. Further, there is evidence to support a number of strategies to reduce inequalities in health, many of which lie outside the health sector.1,2 What has been lacking in most countries is the political consensus and will to implement these. Having made the case for targets in my previous letters to you, I think it would be helpful to set out the issues which need to be considered when setting targets. Governments may have two objectives in mind when they set targets. The first is to ensure that policy is directed towards the achievement of health outcomes and the second is to monitor progress on whether goals are being achieved. It is possible for governments to pursue these objectives separately or at least to prioritise one over the other. It is important to distinguish which of these is being prioritised in order to judge whether the policy to set targets has been successful or not.3 46

FOR AND AGAINST HEALTH TARGETS

Targets need to strike a balance between being realistic and achievable, on the one hand, and challenging on the other. Simple extrapolations of trends are not challenging and will lead to cynicism about the true purpose of targets.Targets need to have credibility with key stakeholders in the system, i.e. those professionals and managers who will be implementing the action to achieve them – these include stakeholders in key sectors outside health, such as transport and the environment. These stakeholders also need to feel ownership of the targets and the health strategy of which they are a part. This entails wide consultation both across sectors and at every level (national, regional, local). This also raises the issue of setting centralised, national targets against encouraging the development of local targets. The balance between the two needs to be carefully considered – national targets may be supplemented by local ones that take into account local conditions and priorities and which allow for local innovation. There are a number of technical issues to consider when setting targets. Strategies may focus only on targets where data are available and the interventions are known or targets could be set to stimulate data collection and the development of new interventions.You have said you will only support targets where effective interventions are known and most argue that targets are more likely to be achieved where good data exist.3,4 The most appropriate type of target needs to be considered.These can include targets for health outcomes (for example mortality, morbidity, risk factor); process targets (for example street lighting, strategy development); or proxy targets (for example sports participation). There are a number of “things to be avoided” when setting targets. These include: target setting without the necessary leverage and resources to bring about change; setting too many targets (the “everything and nothing is a priority” scenario); and the distorting effects of measurement, i.e. the only focus for action becomes what can be measured. An example of this last pitfall is where targets are focused on areas where data are more easily collected (for example acute care) compared with areas where data are more difficult to collect (for example rehabilitation services). I believe that targets for health improvement can make an important contribution to a wider health strategy if the issues I have described above are taken into account. 47

HEALTH TARGETS IN EUROPE

I have very much enjoyed this exchange and have appreciated the opportunity to discuss these issues in a thoughtful way with someone who takes a different view. With best wishes, Naomi References 1 2 3 4

48

Benzeval M, Judge K, Whitehead M, eds. Tackling inequalities in health: an agenda for action. London: King’s Fund, 1995. Acheson D. Independent inquiry into inequalities in health report. London: Stationery Office, 1998. Fulop N, Hunter DJ. The experience of setting health targets in England. Eur J Public Health 2000;10(4 suppl):20–4. Nutbeam D, Wise M. Planning for health for all: international experience in setting health goals and targets. Health Promotion Int 1996;11(3):219–26.

4: Sweden CLAES ÖRTENDAHL

What could targets achieve? “Would you tell me, please, which way I ought to go from here?” “That depends a good deal on where you want to get to,” said the Cat. “I don’t much care where …” said Alice. “Then it doesn’t matter which way you go,” said the Cat. “… so long as I get somewhere,” Alice added as an explanation. “Oh, you’re sure to do that,” said the Cat, “if you only walk long enough.”

The quotation is taken from Chapter 4 of Lewis Carroll’s classic Alice in Wonderland. Common sense suggests that the Cat’s ironic wisdom must also hold true for health and healthcare planning. Sweden may now be on its way to achieving the goal of health planning by the use of targets. A Royal Commission has recently published its proposal to government and Parliament, in which public health targets, with an impressive set of indicators, are a decisive ingredient. It is perhaps surprising to note that these targets are not formulated in terms of health outcomes. The Commission, throughout the three years of its existence, has avoided producing outcome targets. Instead it has focused entirely on health determinants and on policies designed to decrease risks to health. These targets may seem to have been rather slow to appear, particularly since, throughout the history of this very daring endeavour, Sweden has been an active partner in WHO-Euro in the construction of comprehensive targets for Health for All. But in the past health targets have rarely played a role in the national Swedish scene. At the regional level, however, once they were decided on by the WHO Regional Committee for Europe, targets have attracted more attention. Historically, Sweden has little to be ashamed of in terms of its health outcomes. Life expectancy is very high in comparison with other countries in western Europe. Neonatal mortality and child mortality are on a level with the very best in the world and there is general agreement that health is fairly equitably distributed among Swedes. The costs of care are also by no means among the highest. 49

HEALTH TARGETS IN EUROPE

So far health targeting seems to have played a limited role in achieving these good results. Does this mean that health targets, such as those developed in WHO-Euro, are a relatively ineffective way of achieving a high level of public health? Is the format of health targeting suggested by WHO-Euro the only possible way forward or one that could well be substituted by others? The Swedish experience seems relevant to the discussion of these questions.

Making targets work in health development In the following pages a number of target setting exercises will be examined, in order to analyse what works and what does not.The cases that I have chosen need to be understood in relation to the context in which these targets are meant to operate. I have chosen to include targets for the determinants of health and targets for health outcomes and I have done so for the following reasons.To be effective targets need to stimulate a process of public health work. Targets that only focus on outcomes (for example, to reduce cervical cancer incidence by 25%) indicate little or nothing of the causal factors that must be influenced in order to achieve the target. I would argue that outcome targets alone are rather ineffective in stimulating the actions required to achieve them. Also, in some cases, the time lag between the onset of causal factors and the eventual health outcomes is such that we may be unable to see the results in less than the perspective of a lifetime. There is another possibility – the inclusion of targets not only for health but also for health care. Such health care targets entail a number of strategic choices and targeting must include the following elements: ●

●

●

●

●

50

Resources (doctors per 1000 inhabitants, hospital beds per capita, health resources in USD PPP, etc.) Structure (private/public mix, balance of primary, secondary, and tertiary care, etc.) Access (waiting time for first meeting with health care provider, waiting time from referral to acceptance, waiting time for elective surgery) Quality (outcome) (case fatality, perceived quality, responsiveness, case mix balanced postoperative mortality rate, etc.) Equity (differences in resources, structure, access, quality that can be measured as “explained” by income inequality, ethnic inequality, gender inequality, regional inequality).

SWEDEN

Three strategies We may select different targeting strategies with a view to supporting different sorts of health policy processes. ●

●

●

We may wish to construct plans, allocate resources, and create networks for action where the actions of all involved partners are coordinated by a common target. This form of targeting often includes a feedback loop. Such a process includes elements of selfimprovement and correction through a constant follow up of achievements and a feedback of indicator values, in an evaluation to be used by all the participants in the process. By making measurements in health, we may implicitly create targets, without actually having made any explicit and specific predictions about the level or direction of the desired change. We may not know at the outset what levels are achievable. We have to wait and see until the first measurements have arrived.They may then be understood as “good enough” or “in need of improvement”. Comparison between institutions, regions, and countries is an important ingredient of such a process. Gradually steps are being taken in a number of countries to expose providers (both non-profit and for-profit) to markets and quasimarkets. Important ingredients in these processes are producer neutral service targets. Such targets, couched in quite considerable detail, are sometimes introduced as part of the financing system. They may be described as contracting targets which can be used to select between alternative providers.

Health in Sweden is a political area with limited market influence. The processes that create the dynamics in health reflect this. This strongly political character limits the scope for broad, comprehensive use of targets in the process of health governance since the focus on health changes often in the political debate. At one time waiting times for elective surgery dominate, at another, access to organs for transplantation. At yet another the price of prescribed drugs or the need to limit smoking in restaurants comes to dominate the debate. A complex system of comprehensive targets (covering the whole health field) may therefore have difficulty in finding its way onto the political agenda in Sweden. Targets, although political in design, may risk being perceived as merely bureaucratic planning instruments. 51

HEALTH TARGETS IN EUROPE

In a sense the idea of targets, measurements, and corrections had its apotheosis in Soviet style planning for industry and economic development. Behind the political scene in Sweden there are a number of processes that are much more technocratic in character. State or county/municipal bureaucracies, with a high level of independence, may seek to make their work rational, transparent, and legitimate by using a feedback loop strategy and the strong and inflexible rules of bureaucracy are well suited to this.

Legislation and target setting at the central level It is probably important to note the peculiarities of the Swedish health system in order to understand the role that targets have played in health legislation. It is very decentralised, controlled by the 20 counties (and equivalents) and about 290 municipalities that are in charge of health provision. Central government, as an actor in the health field, is limited to a few but important roles. These are: ●

●

●

●

●

●

to assess and defend the economic framework for health in government economic policy to set down a basic legislative framework in matters that need to be regulated with total congruence all over the country (municipalities and counties fight fiercely to keep government out of what they see as “their” territory and routinely seek solutions where national policy instruments are rendered superfluous) to build specialised resources for health that cannot be duplicated at county/municipal level (also a matter of constant dispute) to handle basic relationships between the health sector and other sectors that are regulated at central level, such as training of staff, labour market, environment, communications, etc. to survey the outcomes of the system and intervene, whenever needed, through changes in the regulatory and economic systems to represent the health system in foreign relations and with international bodies such as the WHO and World Bank and to build a system of development partnerships with other countries considering the global obligations associated with health.

It is very important to note that central government has no role in the provision of health services. Indeed, the strong position of local and regional government is further underlined by the fact that they have relatively independent systems of finance based on the right to levy 52

SWEDEN

proportionate income taxes on the populations of their municipalities and counties. Lately, national government has strengthened its position in this area of policy by imposing a number of restrictions on the economic freedom of municipalities and counties. Even so, they remain the dominant stakeholders in health policy formulation and health policy initiatives that erode local government independence and create increased reliance on state financial support are normally vigorously resisted. National health targets need to reflect this distribution of roles and have, therefore, generally limited the targeting policies of central government. At the regional level, where counties are in control, and at local level, where municipalities dominate, targets may play a different role. Swedish health legislation delegates the main responsibility for health to the counties. And it is a very broad and heavy role that they shoulder. “Health care should aim at a good standard of health and health care conditions on equal terms for the whole population.”1 This statement by the legislators of the Health Act has one particular feature that creates problems for health targeting. The responsibility for a high standard of health is an obligation placed on the healthcare system. However, although it is commonly believed that healthcare services play an important role in improving the standard of health of the population, the evidence has always suggested that this role is a limited one. And the problem is further accentuated by the fact that many of the subsequent paragraphs of the Health Act focus even more strongly on health care. In the 1984 proposals to Parliament a more general analysis of this problem took place and public health was given a stronger position in more general political terms. But the legal obligations still emphasised health care, rather than any specific positioning of public health responsibilities in governmental machinery at all levels. The 1991 policy proposals to Parliament gave a stronger direction. Public health improvements were to be achieved through cooperation between sectors. A new Institute of Public Health was created. But the policy in relation to outcomes was predominantly directed towards “equity in health”. Health determinants were specifically noted in the areas of alcohol consumption and smoking but there were no general or comprehensive targets. The 1994 policy proposal to Parliament included the announcement of a new commission to work on these and the “National Public Health Commission” started its work in 1997. The result of this Commission’s work is described later. 53

HEALTH TARGETS IN EUROPE

To what extent can we expect support for setting targets from other pieces of legislation? The Environmental Code offers an interesting example. The definition of “environment” is extremely broad and the tasks are defined in similarly broad terms. The following roughly translated extracts indicate this. For example: “The Environmental Code shall be applied such that the health of men and women is protected against injury and damage whether these are caused by pollutants or by other means …”.2 The Code also distributes responsibilities: “Anyone who plans, or intends to pursue, or pursues, any activity should provide himself with all the information about the activity in question necessary to protect the environment, and to protect the public from injury or discomfort”.3 And the high level of generality in the legislation continues: “Anyone who pursues, or intends to pursue, any activity or plans to make any associated arrangements, shall execute all preventive measures, observe such limits and provide such precautionary measures as are needed to prevent, deter or counteract any injury or discomfort for the public, or damage to the environment arising from such activity …”.4 Based on the Environmental Code, it is thus fair to say that the civic society as a whole is obliged to contribute to health development. And the responsibility for setting targets is a responsibility for all actors in civic society. The role of the political structures is to create the stewardship for health. This, however, presupposes the existence of some form of general understanding in society about the direction in which everyone should pull. All actors are enjoined to decide on targets for their own activities, as they see fit. The Act is prescriptive in one sense but also gives a lot of liberty for groups, organisations or institutions to determine their own strategies – and their own targets. The environment legislation covers most of the public health areas, with one exception: it excludes healthcare services (except as a possible polluter!). It not only covers the activities of public institutions but it also involves society as a whole. It has a broader remit than that of traditional health policy and includes the development of health targets. But the implementation of environmental policies is less clearly located: coordination is clearly a difficult problem, as are the goal conflicts in settling disputes. It is important to note that environment legislation and health legislation are handled by different ministries in Sweden. Although the wording of the environmental legislation seems to expect a very wide and networked cooperation, there are in fact relatively few 54

SWEDEN

examples of actual mutual support between the two ministries. There are also examples of territorial disputes.

Health for all: easier abroad than at home Sweden has been working actively and enthusiastically within the framework of WHO-Euro in the development of the Health for All (HFA) strategy with its originally 38 targets (and indicators). Much, perhaps most, of the Swedish participation in HFA has come from central government bodies. Central government has approved the strategy and indicated that Sweden would consider its implementation. In a number of instances the HFA strategy has been quoted in support of national and regional strategies for public health. Sweden has also actively collaborated with WHO-Euro in the revision of the HFA strategy, and in the design of improved indicators. The targets have been translated into Swedish and given a wide circulation. Nonetheless when, in 1997, the Swedish experience of working with HFA was summarised5 the conclusions were less than enthusiastic.The main equity targets had had little or no impact. The generally positive trends that could be seen in a number of areas of health were not clearly related to work on the HFA policy and in the case of some very important Swedish health problems, such as alcohol consumption, there was little or no progress. There is still no definitive study of the impact of HFA. While the 1997 Swedish study gave some indications of areas where developments had been in line, or out of line, with the targets of HFA, causal relationships between the strategy and the outcomes remain unclear. It can be suggested that central government had too few policy instruments available to be able to incorporate HFA more generally into its national health policy work.While HFA may have been well designed for central government policy making, most of the instruments and the mandate for achieving targets in Sweden were available not to central government but to the counties and municipalities. Local government had not, however, actively participated in the formulation of HFA either in terms of political content or for the processes that were developed for planning, implementation, and evaluation. HFA’s very broad character, then, did not reflect the perceived Swedish political needs. For example, hospital waiting time targets may have been politically significant but were not actively pursued as a target for HFA intervention. In HFA, open doors were knocked on while some closed doors were bypassed without action. 55

HEALTH TARGETS IN EUROPE

The revised version of Health for All 2000, Health 21, has been received respectfully in Sweden but it seems clear that it has had scant effect on the work of local/regional and national target setting. ●

●

●

●

●

Development of HFA targets only marginally involved those who were able to create interventions within their areas of responsibility. Therefore the impact on interventions was marginal or only moderate. The targets were often drawn up to reflect the general status of health in Europe as a whole. A number were therefore irrelevant, or seen as irrelevant, in the Swedish context. The follow up work on the indicators was done at the central level in the Ministry of Health. Those who had real responsibility for the interventions, and who should have been active in using the indicators, were only rarely involved. The number of targets and indicators were such that they could not be handled within the administrative systems and organisations with a responsibility for public health. On the positive side, the system of target setting in health and the use of indicators as part of a feedback loop have contributed considerably to further work in designing public health policy.

In more general terms it may be posited that HFA as a technology has contributed to similar technologies used at local, regional, and national level whereas the policy content of HFA has had a limited impact on health development in Sweden.

The new national perspective The starting point for the National Target Plan has been the policy initiatives brought about as a consequence of government reactions to surveys of public health. The Commission on National Targets, established in 1997, created a vision for Sweden to achieve “good health on equal terms for the whole population”. This was to happen without the legal limitations on the national governance of health care described above. This vision includes six distinct preconditions for health6–8 and 18 associated broad targets. The Commission then made economic recommendations to achieve the targets and described a full list of subtargets and indicators. It proposed a compulsory planning procedure (similar to the welfare accounting procedure described below) and a new Public 56

SWEDEN

Box 4.1 National targets for public health 2000 1. Strengthening of “social capital” – commonality, equality, solidarity

●

2. Good start in life for all children

●

Equal growing up conditions

3. Improved working conditions

●

High employment Good working conditions

●

●

4. Healthy physical environment

●

●

●

5. Health sustaining lifestyles

● ● ● ● ●

●

6. A good infrastructure for health work

●

● ●

●

Strong solidarity and communal spirit Supportive social environment for the individual

Access to green areas for recreation Healthy indoor and general physical environment Safe environment to counteract accident risks and violence Improved physical activity Good nutritional standards Safe sex Decreased smoking Decreased harmful use of alcohol A society free of narcotics Improved health orientation in health care Coordinated public health work Long-term strategies for research, development of intervention methods and training No-nonsense health information

Health Act. The Commission also described the possible means for measurement and suggested a division of work between involved partners. A widened system of health policy evaluation at national level was also proposed. All the Commission’s activities are based on demonstrating an evidence-based strategy for public health. It is of particular importance to note that the targets set up by the Commission are in the health determinant rather than in health outcome format.The argument seems to be that targets which describe health determinants are more likely to suggest the actions necessary to reach them. Further, it is held that the results of these interventions 57

HEALTH TARGETS IN EUROPE

are easier to measure and evaluate. Most decision makers in society do not seem to see any obvious relevance in health outcome targets. They appear to provide limited scope for public health action and the interventions necessary to reach them are believed to be predominantly a matter for the healthcare system. Will health improve as a consequence of the proposed policy of national targets? Very important conditions need to be met if these new targets are to make a real difference. ●

●

●

As in the case of the environmental legislation, a general consensus is needed throughout Swedish society that health, in the broad sense used by the Commission, is so important that goal conflicts must be resolved “to the advantage of health”. The instruments for achieving this are still fairly weak. The economic consequences of a number of possible policy moves are far reaching. Can Sweden afford them? An interesting example deals with segregated housing – social and ethnic groups living in relative or absolute isolation since the economic conditions for renting and buying houses and apartments make integration impossible. This is an important area for public health intervention according to the Commission. Desegregation by means of subvention policies has been an important target for earlier housing policies in Sweden. These policies were costly and were dismantled basically because other needs in the social sector – old age care, child care, education, and health care – were given priority over desegregation in housing in the state budget. The planning processes, at national, regional, and local level and in a number of very important sectors, need to be strongly developed. The argument for such improved planning efforts needs to be very convincing today. Such planning is greeted with less than enthusiasm for a number of reasons – cost, the memory of the limited success of earlier attempts at such planning, and political ideology.

One may perhaps, in conclusion, ask whether the political system is ready to target health to the extent suggested by the Commission. Perhaps that can only be answered with time and experience.

Regional and local target setting for health development In Sweden the high degree of decentralisation of health policy, financing, and implementation of health interventions makes 58

SWEDEN

developments in municipalities and counties particularly important. As a result of cooperation between the Federation of Swedish County Councils, the Federation of Swedish Municipalities, and the National Public Health Institute working alongside seven municipalities/counties, a model has been developed and tested for “welfare accounting”.9 This is the first case of a comprehensive approach to the creation of a “feedback loop” model of local policy making. It includes most, if not all, of the elements of a systematic model – the development of policy, evaluation, and budgeting. The first step involves a general description of health status and environmental factors associated with health, employing the municipality/submunicipality levels as the index populations. The second step requires the budgetary process of municipalities and councils to include critical health areas. Budget directives from the political leadership of the municipality/county will then include the need for health intervention in the build-up to the final budget. This second step also aims to include systematic targeting for both health and social development. The third step constructs a framework for future budgetary decisions, built around a set of key welfare indicators.These represent the situation for individuals, social groups, and regional groups within the municipality, identified by gender and so on. The development of presentation techniques for large databases and the use of the Internet to communicate these databases have contributed strongly to the possibility of building a full picture of most of the relevant health parameters.10 Data that are acquired in this way are used to influence political judgement in 13 key areas. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13.

Health Support for healthy lifestyles Social relations Working conditions General safety Access to health care and social care Employment Education Recreation and culture Economic resources Participation in political and social life Housing and environment Positive future orientation 59

HEALTH TARGETS IN EUROPE

This step also includes analysis of the health consequences of the proposed decisions to be taken by the county/municipality. A more detailed analysis of the situation takes the process to the next step. The fourth step concerns welfare accounts. These are being systematically integrated into the general final accounts of the municipality/county to be part of the budgetary process for the coming year. The fifth step sees the focus thus shifted from analysis and description to systematic interventions as part of the regular budget. A few characteristics of the welfare accounting process need to be particularly stressed. ●

●

●

Decisions on healthcare targets are taken at local level where (compared with decisions taken at national/European levels) there may be greater realism about the budgetary limits for intervention and the local availability of the means to intervene. The “welfare accounting process” is included in the budgetary process, which leads to effective prioritisation of the use of limited economic resources. The follow up and evaluation of the process are stricter than hitherto known in Sweden, are directly linked to a system for modifying the actions taken, and respect the budgetary constraints.

The question yet to be answered is whether the complicated system which consumes time and energy will be respected and put to full use when it is deployed beyond the present seven enthusiastic and pioneering municipalities/counties.

Targets in practice across political levels: the case of road traffic safety Road traffic accidents put a heavy burden on public health. Some countries have managed to limit this and even to bring the number of fatal accidents down. Sweden is one of these countries and is well regarded for its low figures of fatal road traffic accidents. There is a government agency in charge of this work – the Swedish National Road Agency (SNRA) – and its Department of Road Traffic Safety has been particularly active for a long time. It all started with a reform in the 1960s when Sweden changed from left hand to right hand driving. To avoid the feared catastrophic results from this reform, extraordinarily intensive measures were undertaken. A large 60

SWEDEN

organisation was created for the purpose which managed extremely well. Not only was the catastrophe avoided but the incidence of road traffic accidents went down dramatically and Swedes started to reflect on safety measures more than ever. The organisation created for the purpose of the change became indispensable and has been retained. Over a long period the rate of road traffic accidents continued to decline but latterly this rate of decline has slowed. In the mid 1990s a new initiative was started, called “Vision Zero”. In 1995 the strategy for improved road traffic safety proposed a reduction of 50% in the number of fatal accidents by the year 2007. In 1997 this strategy was confirmed by Parliament and relatively large sums of money were set aside by Parliament for this target driven and sustained effort. Initially results were quite convincing but the goal for the year 2000 – less than 400 dead – was not reached. The general trend became uncertain and there were indications of a reversal in the trend of the number of casualties. As so often, it was very difficult to attribute either positive or negative results to this coordinated work for improved road safety. Economic decline during much of the 1990s may have been an important factor in the reduction of average car speeds and the volume of leisure driving.The economic upturn from 1999 onwards may explain the less successful figures since then. But the general impression is that this has been (and continues to be) a successful programme. Is Vision Zero a case of target oriented public health intervention? The target is stated as follows: “The long-term goal is that no one will be killed or seriously injured within the Swedish road transport system”. While no one could object to this, very few will see it as realisable. The target set for the project is more a way of focusing attention on road traffic safety: it markets a generally shared wish to bring everyone on board for joint action against serious or fatal road accidents. The case of road traffic safety illustrates both the advantages of targeting and a number of its attendant problems. Most broad public health interventions involve a great number of partners, who are usually not bound together by formal obligations to act, on the command of a single planner and decision maker. Targets are used here symbolically (to mark a common interest) rather than technically. Vision Zero has been highly successful in achieving this. Without using the traditional prescriptive machinery of a central bureaucracy, it has managed to create a sense of commonality of goals and obligations between a great number of partners, both public and 61

HEALTH TARGETS IN EUROPE

private. They exist at the central/national level and at the regional/local level and are represented by commercial as well as public and non-profit stakeholders. With few formal obligations, they have been able to focus their interest on road traffic safety. Legislation to get all these structures into intensive cooperation has been soft and with almost no use of legal coercion. The fact that considerable economic resources have been available to these partnerships has been important, but there has also been a considerable amount of altruistic enthusiasm for the work fired by the strong message of the target. We still await any ultimate evaluation of this kind of target setting but much already seems to suggest that if the timing is right, if there is an imaginative formulation of targets, and if there is a sense of urgency in society, such targets may have considerable effect.

Systematic health surveillance and “implicit target setting” There are three categories of systematic health surveillance: public health reports, reform evaluations, and quality indicators. Public health reports These have a long tradition in Sweden dating back to the compulsory reporting from provincial doctors in the 18th century.These old reports may still be a goldmine of observations on the historic state of health in the broad population groups of Sweden. The latest public health reports appeared in 2001.11 They now generally focus on four analyses: ●

● ● ●

development of morbidity and mortality in the population and in different population groups the equity dimension of health developments in health determinants the contribution to health development of the healthcare system.

The concept of “implicit targets” may include a general target: for example, “adding more life to years and more years to life”. Another example of an implicit target would be “that greater equity in health should be pursued” or that “important health determinants should improve”. Negative developments in such targets will draw considerable attention and trigger political action. Such implicit targets are inherent in Swedish political culture and are not dependent on any specific decision on health targeting. 62

SWEDEN

Do these public health reports contribute to health improvement? As always, the problem of evidence is very difficult but the following give some indication. ●

●

●

A series of reports demonstrated that “equity in health” had deteriorated. It is clear that this led to a number of local interventions and to a shift in emphasis in national policies. The data on this implicit target contributed strongly to the establishment of the new National Public Health Commission. Data that mental health problems are strongly on the increase have caused considerable concern but little action.There seems to be no outlet for the concern that has been generated and no one really knows how to deal with it but at least the topic is now a matter for debate. Data indicating an increase in the prevalence of health problems in children and adolescents have similarly created considerable attention and a number of actions to counter this development have followed.

Reform evaluation This second category of surveillance oriented health policy may in future play a particularly important role. Two such reform evaluations have been prominent – for mental health and old age. In both cases a number of goals and targets have been set in the national government’s proposals to Parliament and in both cases the National Board of Health and Welfare has been given the task of following up on the outcomes of reform, with generously financed projects. This can only happen when government and Parliament set clear goals and allocate respectable sums of money to county councils, municipalities, and NGOs to implement the reforms. The National Board of Health has, for a period of five years, published annual progress reports, including several which are clearly critical of how the reform has been handled. In these cases the causal relation between the system of target setting, the method of evaluation, the financial support, and impact on health reform is easily distinguishable. It is remarkable that this method of “reform evaluation” has led to a somewhat different approach from government. Whilst government in Sweden has normally acted rather defensively to criticism of those reforms for which it is responsible, it has nonetheless demonstrated from the outset that the feedback loop is itself a part of the reform 63

HEALTH TARGETS IN EUROPE

strategy. Criticism has, in fact, been welcomed. Critical remarks have been transformed into policy change and the implementation of these changes has been quite rapid. Quality indicators This third surveillance oriented approach to health policy developed during the 1990s when a number of initiatives were taken to improve the quality of health care: many of these dealt with access to care. Targets were set in relation to waiting times for elective surgery and for first appointments with doctors in primary care. Links were also introduced between target setting and budgets. Where targets for elective surgery waiting times were not reached, public clinics have had to pay for referral of patients to other clinics, including those in the private sector. Such economic incentives in target setting originated in Norway where they appeared to be very successful.Waiting times went down and general satisfaction rose – finally something had worked! Over time the success of these approaches has become less clear. There have been reports of patients, whose conditions were not included in the waiting list targets, being neglected in order to achieve the targets. There have also been reports that the waiting lists are inaccurate, reflecting the ambition of clinicians to increase pressure on politicians to give them more money. Nonetheless, these approaches to target setting are still held in high regard among many local politicians and frequently quoted in the media when reporting on the state of health care. A different approach is the setting of quality indicators within medical specialities, requiring the registering of quality data in the databases which have existed for a limited number of medical conditions for a considerable time. During the late 1990s the approach developed rapidly and now more than 50 databases covering most of Swedish inpatients are in active use. Implicitly the aim of providers (the “target”) is not to belong to the lowest quartile or quintile in the data set and actions to improve their relative position by healthcare providers have been a notable consequence of the use of these quality databases. They are still not made public, for fear that publicity might prejudice the truthfulness of the data recorded and the high level of participation from clinicians which this confidentiality encourages. The impact of these activities has not been scientifically evaluated but a general understanding is that clinics positioned low in ranking 64

SWEDEN

order have taken strong measures to improve. Also clinical research with a quality orientation has been given a strong boost.

On to new health Sweden has traditionally had a strong public sector providing health care for its citizens. Private forms of provision have been rare and predominantly financed by social insurance. In all sectors, including health, the tendency is to increase private provision of services. The general approach is to keep a strong element of public financing. However, while the trend towards privatised forms of healthcare provision is clear, only a small proportion of all health care, social, and education services has been privatised. Privatisation is still a hot political issue. The government has put forward legislation that makes it illegal to sell public hospitals to private firms, at least for the time being, while the question of privatisation is being considered in government and Parliament. Municipalities and counties with a “left” majority have relatively few examples of privatisation. Some of the major cities and counties with a liberal/conservative majority have taken steps to privatise much of the provision of health care, social services, and education. The County Council of Stockholm has gone further and sold one of its seven hospitals to a group of private investors. Several more are being turned into public companies, transforming them into entities that can be more easily sold. In 2003 all acute somatic care will be included in a “grand scale procurement” process in which the hospitals are to offer quality, prices, and quantities to the purchaser boards of the Stockholm County Council. The organisation of this very large undertaking is well advanced. The general understanding of the political majority of Stockholm County, representing about one-fifth of the total population of Sweden, is that the procurement process and the system of payments and controls will continue to make it possible to keep political control over health care. This will be achieved by the systematic use of quantifiable targets that reflect the political goals of the political majority. The payment system is planned to include target indicators that will make it economically profitable to achieve “production results” that coincide with the goals and targets set up by the political majority. One may presume that non-achievement of quality and quantity targets will become punishable in economic terms. 65

HEALTH TARGETS IN EUROPE

The use of political targets, if these plans are realised, will take on quite a new role. If the policy trends in Stockholm County Council become national trends, the old health policy landscape will have been totally transformed. Some of the problems of implementing political goals in health policy may vanish. Most certainly, others will take their place.

Where are we heading? In the postwar period, Sweden, in line with most economically advanced countries, has experienced a dramatic improvement in its standards of public health. The Swedish model in which this improvement has been realised has included far-reaching decentralisation of health care, a number of policy initiatives for health protection (such as in road traffic safety, food safety, and so on), tax financing, the initially rapid development of an economic framework for health care, and the public provision of services. An important feature has been the close follow up of results. Access to good databases and independent agencies with a mandate to conduct surveillance have created many activities using the principles of feedback loop development. Targets have played a role in this but implicit targets have played a greater role than explicit targets. Implicit targets, however, have also gradually been furnished with more explicit features. Important to note is that these targets have often been limited to a certain sector of health policy – for example, to mental health or old age care. In these contexts the targets and the follow up processes have had a clear impact both on the process of continuous policy development and possibly also on the policy outcomes. The WHO initiatives associated with Health for All have played a role that was not fully understood at the outset. The targets as such have been of limited importance, because the targets in the WHO-Euro version of Health for All were developed for use in Europe as a whole. Their specific relevance to the Swedish scene was, therefore, often rather limited. But the 38 HFA targets have played an important role in demonstrating how a system of comprehensive health policy planning and implementation can be built. Both at the local and national levels, the general features of HFA have been copied and developed. In the impressive plans for public health development in Sweden, put forward in 2000, the WHO-Euro model is clearly visible, although 66

SWEDEN

the detailed content is in part different from it. The focus on health determinants is typical of this (revised) Swedish model. Sweden has never been closer to a comprehensive national public health planning system but the final political decisions are not yet taken. We will know in a year’s time if targeting health in a systematic national health policy will be the answer for the future.The stumbling block could be the wish to focus too strongly on health, in a policy development process that needs to involve a great many other policy areas. And these areas may themselves have ambitions to stay at the centre of interest in the political process. A second obstacle to implementation of a national public health policy, including systematic target setting, is the strong position of local government. Counties and municipalities are known to fight for their independence in relation to central government.They are the dominant stakeholders in Swedish health care and they will set a high price on their participation in any National Health Plan – a very high price. The reluctance to follow the model of HFA targets in a Swedish national health policy cannot be properly understood without grasping the uniquely strong position of local government in Sweden and its very effective defence of independent interest vis à vis central government. Finally, health targets may now become important for quite another reason. The traditional approach to the development and implementation of social policy is being questioned. Privatisation, unthinkable only a few years ago, is becoming a reality in some areas of Sweden.The national government is using legislation in an attempt to stop this process but it is still uncertain whether it will succeed. But it is not the privatisation of health policy that is being contemplated – at least not yet.The example from Stockholm County Council could be interpreted as preserving a strong element of political target setting, perhaps even strengthening it. The proposed “grand procurement process” may be adapted not only for the provision of health care but also for a broader concept of public health. The results of the general elections due in 2002 will probably be decisive in the choices that have now to be made.

References 1 2 3 4

Swedish Swedish Swedish Swedish

Health Act 1982:763 § 2. Environmental Code 1998:809 § 1. Environmental Code 1998:809 § 2. Environmental Code 1998:809 § 3. 67

HEALTH TARGETS IN EUROPE

5 Ministry of Health and Social Affairs. Folkhälsoarbetets utveckling i Sverige (Development of public health in Sweden). Stockholm: MHSA, 1997. 6 SOU. Hur skall Sverige må bättre? Det första steget mot nationella folkhälsomål (How could Sweden feel better? First step towards national health targets). Stockholm: MHSA, 1998. 7 SOU. Hälsa på lika villkor – det andra steget mot nationella folkhälsomål (Health on equal terms – second step towards national health targets). Stockholm: MHSA, 1999. 8 SOU. Hälsa på lika villkor – nationella mål för folkhälsan (Health on equal terms – national targets for public health) Stockholm: MHSA, 2000. 9 A publication describing the process of welfare accounting can be downloaded from www.svekom.se/samhplan/miljosid/valfard. It exists so far only in Swedish. 10 An English version of one of these databases, including advanced presentation techniques for easy access, can be found at www.sos.se/epc, the home page of the National Board of Health and Welfare. It includes around 500 “welfare variables” for all 290 Swedish municipalities. 11 Folkhälsorapport 2001 (Sweden’s public health report 2001). Stockholm: National Board of Health and Welfare, 2001.

68

5: Lithuania VILIUS GRABAUSKAS

Introduction Lithuania underwent considerable changes after regaining its independence in 1990. I propose here to give a brief review of the development of Lithuanian health policies and strategies, in the context of an overall reform of the system of health care. Although the emphasis in this chapter will be on the scientific basis and formulation of health targets, the processes involved in the formulation of Lithuania’s overall health policy, and its implementation, are also highlighted.

Some background information Lithuania is situated on the south-east coast of the Baltic Sea and has borders with Latvia, Belorus, Poland, and the Russian Federation (Kaliningrad enclave). Its territory constitutes 65 300 sq km and its population is 3.7 million, of whom 80.2% are of Lithuanian ethnicity, 9.1% Polish, 8.2% Russian, and 2.5% other. In 1999 the birth rate/ 1000 was 9.8, infant mortality/1000 was 8.3, and life expectancy at birth 72.3 years (for males 67.1 and for females 77.4). The urban/rural ratio was 68:32. The country’s real GDP per capita (adjusted to PPP) was US$4220. Unemployment, however, was reaching 10% and still rising.

Process of health policy development In May 1989 the re-established Lithuanian Medical Association adopted a resolution requesting the health profession and the public at large to develop a new National Concept of Health. The Concept was drafted by a national task force chaired by the author and, after a nationwide dialogue, was approved by the Lithuanian Parliament in October 1991.1 The Concept was based on the Health for All principles developed by the WHO.This suggested involvement in, and responsibility for, the health of all sectors of society throughout the 69

HEALTH TARGETS IN EUROPE

process of health policy formulation and implementation.2 The major steps in Lithuanian health policy development are presented in Box 5.1.

Box 5.1 Major steps in health policy development in Lithuania May 1989 October 1991 March 1993 December 1993 June 1994 November 1995 April 1997 June 1998 June 1998 September 2000

Re-establishment of Lithuanian Medical Association Approval of new National Concept of Health by the Parliament First national health policy conference Establishment of health reform management bureau Adoption of health system law Parliamentary discussion on health system reform Second national health policy conference Approval of National Health Programme by the Parliament Establishment of National Board of Health by the Parliament Third national health policy conference

The strategic framework of the National Concept of Health was based on research findings resulting from population based studies in non-communicable diseases which had been carried out in Lithuania from the early 1970s.3,4 In preparing for the first national health policy conference, the background document Lithuanian Health Report – 1990s was published by the research team of Kaunas University of Medicine. For the first time in the postwar period the health situation in Lithuania was assessed by objective criteria with international comparisons, including trend analyses.5 A similar set of indicators was used to monitor the process of health policy implementation at subsequent stages: the approval of the National Health Programme6 by the second national health policy conference in 1997; the assessment of the health reform outcomes at the third national health policy conference in 20007; compiling the annual reports of the National Board of Health.8 The database for this policy employed a wide variety of variables from health research projects and vital statistics. These reflected known determinants of ill health (behavioural and environmental), levels of mortality, and the performance of health services (including their financial performance). Although the initiative for health policy development (at national and later at regional and municipal levels) 70

LITHUANIA

came primarily from the health profession, the process of its formulation involved a wide range of stakeholders representing governmental bodies, non-governmental organisations, and the academic community. Following a nationwide dialogue, it was intended that the process of health policy development, at all levels of the healthcare system, should follow the scheme presented in Box 5.2.

Box 5.2 Process of health policy development in Lithuania ●

Situation analysis: – – – – – – –

● ● ● ● ●

demographic processes morbidity mortality disability determinants resources trend analyses

Priority setting Target setting Resource allocation Intersectorality/partnership Monitoring and evaluation

Based on the above principles a National Health Programme covering the period 1998–2010 was developed and approved at the highest political level – the Parliament of the Republic of Lithuania.6 This process of health policy formulation and the preparation of a policy document which developed into the National Health Programme were greatly stimulated by the WHO.9

Health situation analysis Assessment of the public health status (by such hard indicators as mortality) had clearly demonstrated that the major health problems in Lithuania were the non-communicable diseases and death from “accidents, injuries and poisoning”. Nine out of 10 deaths were and continue to be caused by this group of conditions (cardiovascular diseases 55%, cancers 18%, respiratory diseases 4%, accidents, injuries and poisoning 13%). These mortality rates were almost twice as high as comparable data in the countries of western Europe and they were rising, not falling. By 1990 this resulted in the perception of a real health crisis. 71

HEALTH TARGETS IN EUROPE

One in four persons at age 24 and above (both male and female) had hypertension by WHO criteria. One in five had hypercholesterolaemia. One in three males and one in two females were overweight. One in two males and three in four females were taking insufficient exercise. The Lithuanian diet was very unhealthy – as much as 47% of daily energy was coming from fats. In nine people out of ten at least one of these risk factors was present.5 Further, it was demonstrated that gross social inequalities and inequities in health existed in Lithuania, despite the fact that we are a relatively small and homogeneous country. These inequalities were assessed in relation to such socioeconomic indicators as education, marital status, family income, place of residence (rural versus urban), etc.10 For all these reasons it was generally accepted that the major objectives for the improvement of the nation’s health should be as follows: ● ● ●

reduction of mortality and increase in average life expectancy focus on equity in health and health care improvement of quality of life.

Targeted structure of National Health Programme A health policy and a set of specific targets (quantitative and qualitative) were formulated to serve two purposes: ●

●

to define the target dates by which the various stages of the major objective were planned to be achieved to monitor the progress of health policy implementation in terms of this major objective – improvement of the health status of the population.

The National Health Programme employed two sorts of health targets. Specific targets indicated the intention to reduce cause-specific mortality and thus to increase life expectancy. Policy targets were employed to track the strategies for achieving this. The targets set up for mortality reduction were based on the results of research projects which demonstrated that vigorous efforts 72

LITHUANIA

in health interventions might lead to a desirable outcome. For example: ●

●

● ● ●

by the year 2010 mortality rates from the main causes should be reduced, thus resulting in an increase in life expectancy mortality from cardiovascular diseases for the population under 65 to be reduced by 15% mortality from cancers to be reduced by 15% infant mortality to be reduced by 30% life expectancy for total population to be increased to 75 years.

Similar targets were set up for mortality caused by mental health problems and suicides, diabetes, tuberculosis, sexually transmitted and some other communicable diseases. All activities in relation to each target area included a situation analysis, the precise identification of the target, the broad strategies for action, methods of monitoring and evaluation. Another set of targets was devoted to strategic actions necessary to achieve the overall objectives. In broad terms they represented interventions in health behaviour (tobacco, alcohol, nutrition, illicit drug use, physical activity), improvements to the environment, and reform of health care (equity, accessibility, acceptability, and appropriateness). For example: ●

●

by the year 2010 the amount of energy derived from dietary fat should be decreased to 30% and the proportion of energy derived from saturated fatty acids to 14% by the year 2010 differences in health and health care between the various socioeconomic groups of the population should be reduced by 25%.

Actions and actors (usually across all the sectors involved) were specified for all these targets.

Monitoring and evaluation Although there were no instruments developed to monitor and evaluate the effects of the implementation of health policy itself, especially its intersectoral performance, the existing national health information system actually permits us to use some indicators which measure changes in the status of the population’s health. It is, however, 73

HEALTH TARGETS IN EUROPE

understood that this type of monitoring and evaluation can by no means be taken as evidence that the existing health policy is efficient or that it necessarily leads to the achievement of its health targets. However, the trend analysis of many mortality indicators now clearly demonstrates that Lithuania has recovered from the health crisis of the 1990s. For instance, in the population aged 0–64, the allcause mortality for the period 1994–2000 is declining by 6.9% per year in males and 6.3% per year in females. Coronary heart disease mortality is declining by 10.0% per year in males, and by 15.6% per year in females. The infant mortality ratio declined from 16.2 per 1000 in 1992 to 8.3 per 1000 in 1999. The health behaviour monitoring project which has been systematically carried out biannually in Lithuania since 1994, as part of FINBALT Health Monitor,11 involves a national sample of 3000 inhabitants. It is demonstrating considerable improvement, for example in dietary habits: between 1994 and 1999 the use of vegetable oil for cooking almost doubled (from 31.1% to 73.5% in the diet of males and from 47.7% to 86.5% in the diet of females). The use of butter on bread decreased from 71.2% to 38.1% (by males) and from 66.3% to 47.3 (by females). The consumption of fresh vegetables has doubled.12 Unfortunately, not all health behaviours are changing in the desired direction – cigarette smoking and illicit drug use, especially among the young, are on the increase (Annual Report of National Board of Health 1999).

Conclusion Although so far there has been no rigorous and comprehensive evaluation of the effectiveness of Lithuanian health policy and its implementation, it can be stated with considerable confidence that the health target approach, employed in the formulation of national health policy, played a very stimulating role. It is also important to note that an intermediate assessment of the policy (although rather limited in scope and execution) suggests that the entire process did succeed in its aim.Three national health policy conferences have been held, with the active participation of the international community and under the stimulating guidance of the WHO.13 The trend analysis of some health indicators has demonstrated that the health target approach to policy and implementation can be considered a useful tool in mobilising the health sector, and the whole of society, to join forces with the aim of improving the health of the population. 74

LITHUANIA

References 1 Grabauskas V, et al. Lithuanian National Health Concept. In: Lithuanian Health Report – 1990s. Kaunas: Medical Academy Press, 1993:86–95. 2 WHO. Health for all targets. The health policy for Europe. Copenhagen: WHO Regional Office for Europe, 1993. 3 Glasunov IS, Dowd JE, Baubiniene AV, et al. The Kaunas-Rotterdam intervention study: behavioural and operational components of health intervention programmes. Oxford: Elsevier/North Holland Biomedical Press, 1981. 4 Grabauskas V. Essential public health objectives in the countries of Central and Eastern Europe. J Public Health 1994;Suppl 1(Beih. 1):8–21. 5 Lithuanian Health Report – 1990s. Kaunas: Medical Academy Press, 1993. 6 Lithuanian Health Programme. Vilnius: Ministry of Health, 1977. 7 Grabauskas V. The process of health policy development in Lithuania (in Lithuanian). Proceedings of the Third National Health Policy Conference, Vilnius, 28 September 2000. Kaunas: Medical University Press, 2000:5–12. 8 Annual Reports of National Board of Health 1998, 1999, 2000 (in Lithuanian). Vilnius: National Board of Health. 9 Dahlgren G, Whithead M. Policies and strategies to promote equity in health. Copenhagen: WHO-Euro, 1992. 10 Padaiga Z, Grabauskas V, Gaizauskiene A, et al., Equity in health and health care in Lithuania: a situation analysis. Copenhagen: WHO-Euro, 1998. 11 Grabauskas V, Klumbiene J, Petkeviciene J, et al. Health behaviour among lithuanian adult population. Helsinki: National Public Health Institute, 1997, 1998, 1999, 2000. 12 Grabauskas V. Nutrition-related health problems in a changing Europe: lessons from Lithuania. Scand J Nutrition 1999;34:26S–27S. 13 Grabauskas V. Health policy development in Lithuania. In: Ritsatakis A, et al., eds. Exploring health policy development in Europe. Copenhagen: WHO Regional Office for Europe, 2000:82–93.

75

6: Spain CARLOS ALVAREZ-DARDET

Introduction During the late 1970s, in response to the WHO manifesto Health for All, the concept of health targets began to be explored in Europe and elsewhere. At this time Spain was undergoing a process of democratic transition which resulted in far-reaching political changes. The country was moving from a dictatorship, which had lasted for 40 years, to become a modern democracy. It also changed from being a very centralised nation state to become a decentralised one, with governance devolved to 17 autonomous communities. Spain thus emerged from a situation of international isolation to become a full member of the European Union and of other transnational bodies. These important moves have had an impact in many areas of Spanish society, including social, and hence health care and public health policy. Arguably the most important achievement in Spanish social policy in the last 25 years has been the development of a welfare state which funded at an acceptable level by contemporary European standards. This democratic transition, and the accompanying devolution of political powers, exhausted much of the political energy of the country. As a consequence the application of health targets in Spain, compared with their application in other European states, suffered many delays. It has also seen by far the most decentralised application of health targets in Europe. The Kingdom of Spain as a whole has never employed health targets in formulating its health policy and in fact has never produced a nationwide health strategy. This is in contradiction to the Spanish government agreements with WHOEuro in 1984, entered into as a member state, and to the domestic mandate of the Spanish General Health Law passed in 1986. Despite this absence of a national dimension, the vast majority of the 17 Spanish autonomous communities perceived a political added value in health targeting and this approach has been used with a rich variety of processes and outcomes. In this chapter the impact of health targeting in Spanish health policy will be described, along with some evidence on its successes 76

SPAIN

and failures. I will comment on the political context and on some of the lessons learned. The Spanish experience demonstrates how social and political contexts can shape the opportunities created by health targeting and make them acceptable to politicians, professionals, and the public. Other countries now in transition, in Europe and elsewhere, may recognise similarities between their own experiences and some of the situations and events to be described here.

The heritage of General Franco’s dictatorship During the 20th century, the Spanish population, like that of many other countries in the south and east of Europe, suffered from dictatorship. Following a military coup in 1936 which resulted in a cruel civil war that lasted for three years, General Francisco Franco became dictator of Spain. His authoritarian regime endured until his natural death in 1975. The social consequences of Franco’s dictatorship were not very much different from those experienced in other authoritarian regimes elsewhere in the past or indeed in the present. The key phrase that characterised the day to day political management of domestic affairs in the country was authoritarian paternalism. The key word that characterised our relationship with the outside world was isolation. Before Franco’s coup, Spain had been developing several promising health policy initiatives. These could be considered as pioneer work for what, much later, became the WHO policy of Health for All (HFA). For example, a network of primary care centres in rural Spain, the so-called centros de higiene rural, was being developed in the early 1930s; so was the pioneering work of Marcelino Pascua in introducing a modern statistical health system for Spain. Many of these developments and innovations were encouraged by the Rockefeller Foundation; its funds helped to create the National School of Public Health in Madrid and to finance the training of an elite of Spanish professionals at American universities. The 1930s was an especially productive and flourishing period for public health and medicine in Spain.1 As a consequence of the civil war and the period of political revenge taking that came immediately after it, all these “golden age” initiatives disappeared.The leaders of these developments were forced into exile en masse or, if they remained in Spain, were repressed.2 The vacuum left by their elimination was very soon filled by politically appointed officials from among the winners of the civil war. In just one day in 77

HEALTH TARGETS IN EUROPE

1940, in a ceremony in Madrid, with all the candidates wearing the regime’s paramilitary uniform, Franco personally appointed all the chairs needed to replace the exiled or killed professors. From that time on until the end of the 1970s, a written certificate of ideological adherence to the ideals of the Franco regime was required in order to obtain a job in the Spanish universities.* While Europe was recovering from the turmoil of the second world war, and many countries began the development of a welfare state (with financial help from the Marshall Plan), Spain, already isolated from western democracies because of Franco’s support for Hitler and Mussolini, increased its isolation still further. The country had also become markedly impoverished. The level of the Spanish GNP in 1936 (the year of Franco’s coup) was not reached again until 1959. All political parties, with the exception of Falange, the fascist party which supported Franco, were forbidden. So were the trade unions and many of the professional associations. By the 1930s several of the communities had already obtained a high degree of self-government – in particular the Basque Country and Catalonia, which had fully developed their own autonomous governments. At the time of the Franco coup, Galicia and Andalusia were also trying to pass their own self-government laws. These devolutionary processes were completely stopped by Franco who declared illegal all the cultural manifestations of the diversity of Spaniards, including the use of Euskera and the Catalonian and Galician languages. The effects of this mixture of international isolation, internal censorship, authoritarian control, and poverty are easy to imagine. The dictatorship affected all aspects of the training and development of health professionals. Medical colleges were “reformed” and left without many of their previous competencies. The Ministry of Health ceased to form part of the national Cabinet from the end of the civil war in 1939 and this state of affairs persisted until the reintroduction of a democratic government in 1978. As a consequence, health policy was fractured into myriad entry points in the enormous Franco bureaucracy.

* This was a written statement on the General Principles of the National Movement with ideological adhesion to Falangist ideas. I was forced to sign one of them to obtain my first job as lecturer in the Seville University as late as 1979. Shortly after this the requirement was abolished by the first democratic UCD government. 78

SPAIN

In 1953, following the trend in other European countries that were developing publicly funded health care, Jose Antonio Girón de Velasco, a Franco minister and Falange trade unionist, created a publicly financed healthcare system within the established Spanish social security system. This was basically a Bismarckian model of public healthcare services and resulted in an underfinanced, piecemeal, and paternalist new body. Because this social security system was imposed by the regime, there was little sense of ownership of the public services by the public. Finally in the 1960s, with improvements in the economic situation, the Franco regime produced its unique achievement in health policy. This was the creation of mammoth hospitals in the bigger Spanish cities, with some thousands of beds, as the flagships of the regime’s health policy.

A coincidence: Alma-Ata and Spanish democracy In the early 1970s several worldwide forces started to shape the idea of Health for All as a value base for the development of health targets. Some of the elements of this shift in values came from critical thinking in medicine; others originated in economic or geopolitic critiques. Critics of the then mainstream and prevalent medical thinking, for example Thomas McKeown,3 Archibald Cochrane,4 Julian Tudor-Hart5 and Ivan Illich,6 paved the way for an in-depth reconceptualisation of public health and healthcare services.7 These thinkers raised important questions about the true role of medicine, the societal causes of illness, the effectiveness of medical care, and the need for a new kind of (primary care) doctor. In 1973, following the crude oil crisis, politicians were forced to consider how to deal with the increasing financial costs of public services. In the United Nations a coalition of European Social Democrats and the movement of non-aligned nations provided the political leverage to bring about an important change in the policy of the United Nations and hence of some of their social organisations like the WHO, UNESCO, and UNICEF. Consequently the traditional medical colonialist WHO policy8 was replaced by a more egalitarian and participatory vision of health policy, encompassed by Health for All. Health targets were the logical consequence of this new value base. Nation states were now called upon to accept responsibility for promoting the health of their entire populations. 79

HEALTH TARGETS IN EUROPE

Of course, in those years, the medically dominated, intellectually isolated, conservative and authoritarian healthcare machinery of Spain was not at all sensitive to these innovations. Also, in spite of experiencing a major economic recession with high inflation rates, cost containment in health services was not a political priority as far as the Franco regime was concerned. Its political priority at that time was focused on its own political survival. Nonetheless, as the possibility of a re-emerging Spanish democracy came to be seen as increasingly feasible, the democratic opposition to Franco (Plataforma y Junta Democraticas, assembled around two big coalitions of the then illegal political parties and trade unions) became passionately interested in using these new ideas as the framework for shaping the future of Spanish health services. Under the previous regime the quality of primary care in Spain was extremely poor. It was underfinanced; there was no postgraduate training for primary care personnel; it was delivered by several different bodies; there were different standards of care in rural and urban areas; and there were variations in entitlement and quality that depended on the kind of insurance held by different groups of workers. Just as hospitals were the flagship of Franco’s health policy, so the creation of a decent primary health care within a true national health service became the linchpin of the political opposition’s health agenda. Against this background, the seminal critical ideas current in the 1970s, which later would lead to the WHO HFA strategy,9 were strongly supported by the democratic medical elites, trade unions, and political parties in Spain and a few pioneering primary healthcare projects were developed. HFA started to exert influence in Spain, informally at first, by being taken into account by the democratic parties without any kind of official endorsement by Spanish governments. Later, in this informal and indirect way, both the Alma-Ata Declaration and the 38 Health for All targets of WHO-Euro10 shaped and influenced the Spanish General Health Law and the developments of the new Spanish NHS.11 Several primary healthcare pioneering projects began their development during the democratic transition in Spain.They attempted to adapt the ideas of a new kind of primary healthcare centre to the country’s situation. A few clusters of professionals committed both to the democratic reforms and to the new model of primary care started to develop the first experiments in Montanchez in Extremadura, later in La Cartuja in Andalusia and Tirajana in the Canary Islands, and then in Barcelona and Valencia. These projects, developed without any help 80

SPAIN

from the Spanish government, were true experimental laboratories and became models of good practice. They shaped a vision of the reformed Spanish health services, which was later put into practice by the democratic governments. It is a happy coincidence that the Alma-Ata conference was held in the same year as the first Spanish elections after the dictatorship.

Social policy in a quasi-federal state Following these democratic elections there were four years of conservative governments (Union de Centro Democratico) from 1978 to 1982. In that period the political agenda of the country was overwhelmingly dominated by the need to consolidate the young Spanish democracy and further to develop the process of devolution to the autonomous communities. The major issue in health policy during this period was the reconstitution of the Spanish Ministry of Health, abolished in 1939.This ministry brought all the administrative bodies with competencies in health matters under the same political authority and administrative umbrella and began the process of decentralising decision making to the autonomous communities. There was no political energy to develop health policy beyond these fundamental reforms. In spite of all the efforts made to consolidate the new democracy, in 1981 there was another coup, with the Guardia Civil Tejero taking over the Spanish Parliament.* This failed in 24 hours. In the same year as the Tejero aborted coup, the 33 member states of WHO-Euro officially endorsed the HFA European policy and the later very influential 38 health targets. In 1982 the Spanish Labour Party (PSOE) won the elections. Its electoral programme included the change of the Spanish social security system into a national health service, the design of which had been much influenced by HFA. * The Tejero’s attempted coup gives an idea of the importance of political authoritarianism in Spain, even eight years after Franco’s death. Although the coup only succeeded in taking over the Parliament in Madrid with all the MPs inside, and in the military occupation of the city of Valencia, there was real danger of revolution. Just the building of a democratic system took a lot of the political energy in those years in Spain. On the day of the coup I was teaching an afternoon seminar to my students on … the right of women to abortion! The seminar was interrupted by one student giving the news of the coup. We decided to end it immediately. Each of us started to look for the safest possible place to spend that night. 81

HEALTH TARGETS IN EUROPE

In the course of the 1980s, Spain, under its Labour governments and like a number of other southern Europe countries, moved from a social security system towards the creation of a true national health service. The creation of an NHS was at the centre of the health policy debate during the 1980s and was the objective of the Spanish General Health Law (SGHL) passed in 1986. As far as health targeting was concerned, the SGHL established the principles for this in a very decentralised way. Each autonomous community was given the responsibility of developing its own health plan, leaving the Ministry of Health in Madrid with the mandate for giving coherence to a nationwide “integrated health plan” for Spain. The Spanish NHS is perhaps the most decentralised system in WHO Europe. Its shape has been strongly determined by the organisation of Spain as a quasi-federal state. All areas of public governance were fundamentally redefined, though the extent of this depended on the level of decentralisation of competencies in the various autonomous communities. All the 17 Spanish autonomous communities were given a measure of responsibility for public health. Some, like Catalonia, the Basque Country, Galicia, Navarra, Valencia, Andalusia, and the Canary Islands, were also given full responsibility for the provision of healthcare services. The least expensive part of the health service – namely public health – was the first to be devolved.This happened in the early 1980s (in Catalonia, in 1979). Those autonomous communities which had had most competencies devolved to their governments (Catalonia and the Basque Country) began the process of decentralising their health services. This decentralisation also affected the development of health targeting, which thus became primarily a task for the governments of Spanish autonomous communities.

Health targets in Spain The formal endorsement of the WHO-Euro HFA policy by the Spanish government did not occur until 1990.The delays were caused by the time taken to move to a democratic form of government and the introduction of devolution to the communities. 1990 had in fact been the deadline proposed by WHO-Euro in 1984 for its member states. Most autonomous communities in Spain have now employed some health targeting but with considerable variety. By instituting a process of consecutive and formal health strategies, with evaluations, a few of the communities (Catalonia, Navarra, the Basque Country, 82

SPAIN

Andalusia, and the Canary Islands) have made serious progress in health targeting. In other autonomous communities, as governing parties have changed and partisan quarrels have broken out, the implementation of health targeting has waxed and waned.12 A good example is the Valencian community. In the early 1990s public health assessments and health priority papers were produced which resulted in the formulation of a health plan, published by the Valencian government in 1995. Then there was a change of government from Labour to Conservative, which arrested the previous developments, dismissing them as a “Labour inheritance”. Very recently, after seven years of silence, the Valencian government is now reinventing the wheel and again producing a new health plan. The first formal Spanish health target documents were published in the early 1990s. These documents were the starting points for the use of health targeting by the regional Ministries of Health of Navarra, Catalonia, Andalusia, the Basque Country and Galicia. For the most part the autonomous communities used the WHO-Euro 38 targets as a common “umbrella”. As one might expect from a process of decentralised decision making, but within a common national framework, there were both marked similarities and differences in the execution of the different regional plans.13 The methods of consultation and the priority setting procedures varied widely.The vast majority, however, gave evidence of only a limited consultation process, the most “obvious” stakeholders – the health professionals – being the ones principally consulted. Only the Canary Islands health targets were based on an open, participative consultation process. However, this open approach also ran into its own difficulties. The Canary Island Plan identified more than 400 targets and it proved hard to prioritise these. It also became apparent that the various Spanish health plans differ from one another in their underlying values. An instrument for comparing them was developed by Rosana Peiro.14 She used a rapid appraisal methodology: for example, the health targets developed by the Catalonian government were compared with those developed by the Valencian. She found that the Valencian community health strategy was based on the values of public health, while the Catalonian was based largely on values concerned with medical interventions at the individual level. Some health strategies were initiated by the regional Ministry of Health, others took the form of a public commitment of the entire autonomous government and represented a consensus among all the 83

HEALTH TARGETS IN EUROPE

parliamentary parties involved. Yet despite this seemingly high political profile, there was no budgetary support for the emerging health strategies in Spain. Nor was there serious political debate about health strategy and planning in the autonomous communities Parliaments. Political parties in the opposition failed to ask parliamentary questions about health targets and showed little interest in monitoring their progress. Health targets were simply not regarded as a useful tool for political accountability. Further, with the exception of the Spanish Public Health Association (see below), no Spanish medical or nursing professional association or consumer association attempted to hold governments to account, in terms of the health targets to which they had committed themselves. While it is true that, as a result of the WHO-Euro Healthy Cities Project, some cities have expressed their health policies in terms of targets, only Barcelona has produced explicit targets for the city and has made progress with their evaluation. The Spanish Ministry of Health15 has never launched a true nationwide programme of health targeting either in relation to Health for All or the more recent WHO Health 21 strategy.

The Spanish Public Health Association assessment The Spanish Public Health Association (SESPAS) is a professional society with some 4000 members. Every two years it produces a report on the state of health and health services in Spain. In 1998 SESPAS convened an independent group of professionals who were invited to evaluate the achievements of health targets in Spain. Since the Spanish Ministry of Health has never formulated its own health targets, SESPAS employed the 38 WHO-Euro targets as benchmarks.The first draft was posted on the Internet for discussion and finally presented and discussed at the 1999 SESPAS meeting in Seville. The report was published in 2000.16 About half of the 38 Euro targets were in fact achieved, for example concerning infectious diseases, childhood health, CHD, water quality, and food safety. However, among the targets not achieved in Spain for the year 2000 were the (especially important) ones concerned with equity, cancer, traffic and occupational injuries, mental health and suicide, smoking and alcohol, disabled people, environmental health, community care, information systems and research and training. 84

SPAIN

The SESPAS 2000 Report affirmed that Health for All and the 38 Euro targets were crucial in shaping the future of the Spanish National Health Service and in developing a robust primary healthcare system. Although these WHO policies have had some impact on the national political rhetoric and on some of the policies of some of the autonomous communities, under the Spanish Conservative government now in power there has been little progress and little more can be expected in the immediate future.

The Las Palmas Declaration In November 2000 SESPAS held a workshop in the Canary Islands which brought together professionals and politicians with experience in formulating and implementing health targets. The title for the workshop was “Health targets: a planning tool for the needs of the new public health?”. At its conclusion the participants endorsed a resolution, called the Las Palmas Declaration, which was later published by the SESPAS journal, Gaceta Sanitaria. This declaration is a good reflection of the state of health targeting in our country, as perceived by professionals who have been involved in such projects for the past 15 years. Because of its importance as a “collective voice”, as a record of how much has been achieved and as a view of what is needed for the future, an English translation is reproduced in Box 6.1.

Box 6.1 The Las Palmas Declaration If an equitable health gain for every Spanish citizen is pursued, the following recommendations should be taken into account based on the accumulated experience with health targeting for the years to come. ●

●

●

●

The formulation of health targets in the last 15 years in many Spanish territories has mobilised resources, aroused expectations, and developed visions for better health which should not be frustrated. The WHO-Euro Health 21 strategy and its 21 targets for the European Region should be a framework and reference for future strategies in Spain. Every effort should be made to support it. A rethinking process is needed to adapt health targets to a globalised world within the information society. Think globally and act locally means a “glocalisation” of practices and programmes. Planning exercises, information systems, and social accountability should also be “glocalised”. The political support of health targets should express itself not just at a rhetorical level but also at a financial one. Health plans should have 85

HEALTH TARGETS IN EUROPE

●

●

●

●

●

●

●

●

●

●

●

●

their budget provisions and be passed by all the pertinent institutions and bodies. Intersectoral action is just rhetoric if the budget responsibilities of all the involved parties are not clearly defined. Health targets are tools for goal oriented health policy. Due to this, targets should be translated into actions by using them to shape the different managerial tools used in the health services, so that application in practice can be guaranteed. The health of the public should be mainstreamed in the political agenda and in social debates. This is imperative in a globalised world with increasing inequalities and emerging diseases. Health targets should be discussed and eventually accepted by the highest Cabinet level as a responsibility of the entire government. The different health strategies developed so far by many autonomous communities in Spain are an important pool of experiences and know-how which should be taken into account in future endeavours. To attain this a political approach based on alliances and synergistic efforts is needed. A health information system outcome oriented with ability to identify health needs, monitor and evaluate the efficacy of interventions is needed. To keep health targets alive and well more and new research is crucial. This should be based on action oriented research questions and performed by multidisciplinary and multicentric teams. The definition of health policies and targets should not be just coherent with national and regional ones but also with local policies. Local participation of citizens is crucial to define health needs. Contracting healthcare services is not the only available tool to advance health targets. Other intersectoral tools should be explored and used in the future. The Spanish experience concerning the “first generation health strategies” developed upto now have added important value to the Spanish health services. In moving towards a “second generation”, budgeting of programmes is clearly needed. There are scientific tools to assess health targets formulation and monitoring. Their assessment should be an exercise of transparency in a socially accountable framework. This means an important cultural change. Community participation should be guaranteed at every step of the health targeting process in order to guarantee its effectiveness and efficiency. To attain this, formal entry points with enough resources should be designed. The feasibility of health strategies depends heavily on how public health associations develop a leadership role in mainstreaming health among both health professions and politics.

This declaration is endorsed by the participants of a workshop sponsored by the Canary Islands Public Health Association and the Spanish Public Health Association.

86

SPAIN

Conclusion Long overdue social changes can only occur when they are coordinated and simultaneously driven at the levels of political rhetoric, policy making, and practice. Because targets are tools which encourage communication between these three levels of change, they are capable of producing coherent improvements. They permit achievable visions of better health to be transformed into policy and actions and so they can directly affect health behaviour and professional practice. For this to come about it is necessary for health to be seen to be in the mainstream of political concern. In Spain, because of its social history and political context, the introduction of health targets has been delayed and decentralised. Also there have been no serious attempts to cross the borders between political rhetoric, policy making, and actual practice. Changes in the rhetoric have not been negligible in Spain but changes in rhetoric are not enough. Health for All and the idea of health targets have informally contributed to shaping many experimental projects designed to improve our health. These constitute both a rich laboratory of experiences and a reservoir of ideas, on which we can build in the future. Acknowledgements To Rosana Peiro and Andreu Segura for their kind comments on previous drafts of the chapter. References 1 Bernabeu J. El papel de la Escuela Nacional de Sanidad en el desarrollo de la Salud Publica en España,1924–1934. Rev San Hig Pub 1994;68:65–89. 2 Marset P, Rodriguez Ocaña E, Saez Gomez JM. La salud Pública en España. Segunda etapa: la sanidad durante el franquismo. La creación de un modelo sanitario autoritario. In: Martinez Navarro F, ed. Salud Publica. Madrid: McGraw Hill, 1998. 3 McKeown T. The role of medicine: dream, mirage or nemesis? London: Nuffield Provincial Hospitals Trust, 1976. 4 Cochrane AL. Effectiveness and efficiency: random reflections on health services. London: Nuffield Provincial Hospitals Trust, 1972. 5 Tudor Hart J. A new kind of doctor. J Roy Soc Med 1981;74:871–3. 6 Illich I. Medical nemesis. Lancet 1974;ii:918–21. 7 Alvarez-Dardet C, Ruiz MT. Thomas McKeown and Archibald Cochrane: a journey through the diffusion of their ideas. BMJ 1993;306:1252–4. 87

HEALTH TARGETS IN EUROPE

8 Mahler H. Health – a demystification of medical technology. Lancet 1975;ii:829–33. 9 WHO. Alma Ata 1977. Primary health care. Geneva WHO, 1978. 10 OMS. Objetivos de la Estrategia Regional Europea de Salud Para Todos. Madrid: Ministerio de Sanidad y Consumo, 1986. 11 Lluch E. Politica general del ministerio de sanidad y consumo. Madrid: Ministerio de Sanidad y Consumo, Servicio de Publicaciones, 1985. 12 Gispert R, van de Water HPA, van Herten L. La introducción de objetivos de salud en el marco de la politica sanitaria española. Gac Sanit 2000;14:34–44. 13 Repullo JR, Otero A. Planes de salud: sueño, espejismo o nemesis. Gac Sanit 1999:13:474–7. 14 Peiro R, Alvarez-Dardet C, Borrell C, et al. Metodología rápida para el análisis de la formulación de políticas de salud. Gac Sanit 1999;13 (Suppl 3):7. 15 Plasencia A, Manzanera R. La nueva estrategia europea:una oportunidad para la Salud Publica espoañola. Gac Sanit 2001;13:1–3. 16 Alvarez-Dardet C, Peiro S. Informe SESPAS 2000. La salud publica ante los desafíos de un nuevo siglo. Granada: Escuela Andaluza de Salud Publica, 2000.

88

7: Germany HANS STEIN

The general background for target setting Most countries – the people, governments, and political parties – are on the whole proud of their political and social systems and their institutions. This of course applies to many political areas but it applies especially in relation to health. For a variety of reasons the health system stands out as the one area of political national development that excites much debate, perhaps because of all political topics, health reflects the peculiarities, traditions, and national cultures to the greatest degree. The European systems differ tremendously, with the Bismarck system on the one hand and the Beveridge system on the other representing two endpoints of parallel but very different evolutions. These different health systems are the result of decades of development and are the direct response to each country’s social situation, profile, and experience. Therefore in the process of European integration, the social and cultural traditions of the various social security systems must be taken into account and their integrity secured. Safeguarding the pluralism of the national health systems existing in Europe seems to be a salient value in itself.Whenever and wherever health targets are being established this diversity has had to be taken into account. If health targets are described as something different from, and more than, expressions of pre-existing aims for health policy and action, but, rather as specific instruments designed to make health policy transparent by setting quantifiable and measurable objectives to improve health, then, so far, the German national experience of health targets can in no way be described as a success story. The simple truth is that, at least at a national level, so far there are no outcome oriented health targets in Germany. However, here I intend to describe the different attempts made in the past, and to draw lessons from them, so that future attempts may be more successful. A survey conducted in all EU member states by the London School of Economics in 1996 showed that on average 8.8% of the population were very satisfied with their existing health system, 41.5% were satisfied, and only 18.8% were not satisfied at all. Of course, there 89

HEALTH TARGETS IN EUROPE

were national differences. In Germany 12.8% were very satisfied, 53% rather satisfied, and only 4.8% were not satisfied at all. Given this situation it is not surprising that the member states of the European Union: ●

●

● ●

were very much against even the smallest degree of harmonisation of healthcare systems in the process of EU integration reacted very negatively when, in 2000, the WHO in its World Health Report published a worldwide ranking of national health systems did not like to be told by others what to do in health policy especially did not like to be told what targets they should adopt.

In consequence, and despite the existence of all kinds of international cooperation and experience sharing, the setting of health targets at a national level can only be a task for the country itself. It cannot be prescribed by international or supranational institutions such as the WHO or the EU. International institutions can be very helpful in initiating the idea of target setting by developing different methods. They can even monitor the different national and regional activities and they can compare them. However, as international institutions which have to respect national responsibilities and competencies, they cannot be an integral part of national health target setting. The target setting process can therefore only be successfully undertaken by those for whom the targets are intended, be it at the local, regional, or national level. Above all, health targeting has to take into account the characteristics of the pre-existing indigenous health system – something that outsiders are rarely able to do. The question to be answered, against this background and learning from past experience, is this: does the German health system need health targets and if it does, how they can be established and implemented?

Targets and the German healthcare system Because of its diversity and the way responsibilities in German health policy are divided between different actors, all eager to maintain their power and influence, it has been and remains tremendously difficult to achieve some kind of consensus about the need for, and value of, health targets as an instrument of policy at all the different political levels. 90

GERMANY

It is beyond the scope and purpose of this chapter to describe the German health system in detail, although in order to understand the implications for setting targets, it is important to note that it is highly decentralised. Its most striking components are as follows. ●

●

●

●

There is a division of power and competence between the federal government in Berlin and the 16 Laender. As far as the state is concerned, it is not with the federal government but with the Laender that the legal competence for health matters lies. Thirteen of the Laender have ministries that include the word “health” in their names. These are mainly responsible for public health and for maintaining hospital infrastructures. Power is delegated to non-governmental corporatist self-governing institutions such as statutory health insurers contracted with physicians and dentists: legal associations on the provider side and sickness funds and their associations on the purchaser side. There is a clear institutional separation between public health services, primary and secondary ambulatory care through office based physicians, and hospital care which has been traditionally confined mainly to inpatient care.

The simple truth is that whatever health targets are decided at the federal (Berlin) level, it is not this level that has the power and legal competence to implement them. This nearly always resides at another level, for example in the Laender and the non-governmental corporatist institutions. Can the federal government tell these bodies what to do? Germans take the relationship between the Laender and the federal government for granted. It is a part of their everyday political life. For outsiders this special relationship is difficult to understand. To put it simply, in areas where they have responsibility the German Laender are completely independent and health is one of these areas of responsibility.The federal government has very little direct influence here. Nevertheless, there is need for coordination and agreement on matters of common interest. For this purpose the so-called Laender conferences take place, as a rule once a year. Here ministers from different areas of policy (health, interior affairs, labour, agriculture) meet to discuss solutions to common problems. In many ways this work is similar to the processes of the European Union in Luxemburg. A representative of federal government, in this case the Federal Health Minister, is only a “guest” at these deliberations and has no vote. 91

HEALTH TARGETS IN EUROPE

Two conclusions can be drawn from this unique situation: ●

●

it is enormously difficult to achieve the necessary consensus on health targets between all the different actors and stakeholders in determining health targets, such a pluralistic system needs to function by consensus far more than might be necessary in a centralised state run health system.

This need for a broad national consensus is widely recognised in Germany and several attempts have been made, and are still being made, to create national health targets.

The past (1983–1993) The first attempts to develop health targets in Germany at the federal level took place between 1983 and 1993. Despite the fact that this initiative was not a success, a lot of lessons can be, and indeed have been, learned from it. There were two quite separate reasons for the first initial steps. In 1984 the European Region of the WHO formulated 38 regional health targets as a part of the Health for All strategy to which the Bonn government committed itself although it did very little to implement this political commitment. First, although the influence of the WHO on German health policy and the health system was rather limited, the Ministry of Health at that time felt if not exactly a legal, then certainly a moral and political obligation to do something about implementing the WHO strategy and especially to act on health targets. Second, and more importantly, there had at that time been a change of government in Germany. At a special meeting of the heads of the German doctors’ associations and Bundeskanzler Kohl in 1984, it was agreed to work together on the idea of health targets and to make health targeting the topic of a broad scientific discussion. The intentions of the medical professional organisations were, and remain, quite clear. For years health policy in Germany has been largely dominated by cost containment issues. All health reforms and laws included one over-riding health target – to stabilise the rate of the contributions payable to the statutory insurance funds. The medical professions considered this, quite rightly, to be only a financial target and not a real health target. It was hoped that by using empirical evidence about the incidence, distribution, trends, risks, and facts of diseases, true health targets could be established that would counteract 92

GERMANY

the purely financial and economic indicators which for so long had been dominating the healthcare system debate. It was further hoped that these new health targets could play a decisive role in the allocation of funds for health care. What happened? Financed by a research grant from the Health Ministry, a working group on Priority Health Objectives was founded by the Federal Minister for Health and representatives of the German medical profession. At the start, the task of this working group had been to determine national health targets which could and should form the basis of future decisions on healthcare expenditures. Eventually, the group focused on identifying the most important health problems of the German population. The intention was to base the creation of health targets on evidence from health research and to provide a research based rationale for the criteria to be employed. The result was a relatively comprehensive and systematic survey of the health status of the German population. About 70 different health problems were identified and described in relation to the following characteristics. 1. Definition of the problem 2. Prevalence: 2.1. in the country as a whole 2.2. in inter-regional comparison 2.3. in international comparison 2.4. trend 3. Severity 4. Risk factors: 4.1. relating to the incidence of new cases 4.2. relating to an unfavourable course of disease 5. Possible measures to improve the present situation 6. Perspectives The publication of this survey was thought to be helpful as a guide, especially for health politicians. It would help them to orient themselves in relation to the wider field of health related and sociomedical facts, factors, and inter-relationships. By the time that this report was published and presented by the German Health Minister, it was already out of date and consequently 93

HEALTH TARGETS IN EUROPE

received only limited attention. Furthermore, by then the Federal Republic whose health problems were described in the report no longer existed as a discrete political entity – the unification of the two Germanys had taken place only two months before. The new Federal Republic of Germany now had some 30 million new citizens with a health status very different from that of the former Republic. There were other pressing problems to solve at that time, including problems in health policy, and establishing common health targets for the new Federal Republic was not considered a high priority. The main, and difficult enough, task was to transform the former centralist, national healthcare system of the German Democratic Republic into a pluralistic one and to provide the financial resources to improve the rather disastrous state of affairs that existed in the health institutions of the former East Germany. Nevertheless, a second publication was prepared and published in 1993 called Indicators of the Health Status of the Population of the Former German Democratic Republic. By using the existing East German data and exactly the same methods as those used in the previous publication, a detailed description was given of the five new East German Laender. However, no attempt was made to combine the two presentations in order to arrive at some kind of common target for the two parts of the now reunited country. Even if one had wanted to do that, it would not have been possible by just adding together the facts and figures. Lessons to be learned Although, for all these reasons, the second part of the project – the formulation of health targets themselves – was not completed, a number of lessons can be learned that should be taken into account in future initiatives. ●

●

●

94

There has to be an expressed political will and an explicit political commitment to establish health targets as a binding political instrument; an exploratory research activity might be needed as a basis for this, but by itself it is not enough. Targets cannot be established by a top-down process, especially not by order of the government. They can only be established as the result of a transparent, broad, scientific, and political discussion. Targets cannot cover every topic. They have to identify priorities and therefore posteriorities. The chosen priorities must be given

GERMANY

●

●

the necessary legal, financial, and personnel resources. Targets by themselves can achieve very little unless they are implemented within the health system, because they need the support of the system. The process of defining targets, and the political decision to implement them, necessitate the full participation of all actors and stakeholders.This makes the process slow and difficult, but without such attention to detail implementation is virtually impossible. Most of all, targets can only become effective in a generally target friendly climate. Targets have to be accepted not as something strange and foreign to the health system but as a useful and needed contribution for improving the system and thereby the health of the population. This target friendly climate is not something that just happens; it needs to be created and stimulated. If it already exists it can be improved by initiating a broad and open strategic discussion which includes all interested partners. This climate did not exist in Germany in 1990 or 1993. Does it exist today?

1997–2000: from medical orientation to health targets Strange as it may seem, despite, possibly even because of, the lack of federal government dominated activity in health targeting, this positive climate does now seem to be becoming a reality. It would not be an exaggeration to talk of a health target revival since 1997, even a permanently growing health target movement in Germany. This surprising development seems to have been triggered by a growing dissatisfaction with progress and doubts about the ability of the German health system to achieve the necessary changes by the usual means of big and fundamental reforms, which take place every two years. There seems to be a growing consensus among many decision makers that only outcome related health targets can encompass and reflect the varied perspectives of such new developments as evidence-based medicine, quality assurance, health technology assessment, and clinical guidelines. This process has been influenced by an intensive and transparent dialogue between the scientific public health community (the Medizinische Hochschule Hanover playing a leading and very dominant role) and health policy decision makers, especially at the Laender level. Here North Rhine-Westphalia took the lead in introducing many initiatives. The medical profession and the sickness 95

HEALTH TARGETS IN EUROPE

funds also played an important part. This process seems to have started simultaneously in many different parts of the health system. The necessary transparency was created by a number of publications, sometimes whole editions of journals being given over to the topic of health targeting. For example, one edition of the Gesellschaftspolitische Kommentare was completely devoted to essays on the topic of health targets. Also, for a variety of reasons, many companies in the pharmaceutical industry took a very supporting interest. The implementation of health targets is increasingly being accepted as a pragmatic and systematic attempt to reintroduce a health orientation, as opposed to a purely economic orientation, in health policy making. This situation has lead to quite a number of activities in the Laender as well as to pilot projects by non-governmental self-regulatory agencies at local and regional level. Since the mid 1990s quite a number of Laender, such as North Rhine-Westphalia, Hamburg, Berlin and Saxony-Anhaltina, have begun work on targets and established them. How this was done in North Rhine-Westphalia is described by Dr Birgit Weihrauch in the following chapter. Politically even more significant than work on these Laender targets was a resolution by the German Health Ministers’ Conference of the Laender (GMK).This is a regular meeting of Laender health ministers to agree on all matters that require a common approach. In 1999 they passed a resolution on Targets for Health Policy which not only described the need for and importance of health targets in a pluralistic health system, but specifically asked the Federal Ministry of Health to “moderate this process at a federal level”. This resolution, to which all the Laender agreed, even those in usually very outspoken opposition to the central government in Berlin, demonstrated the need for targets at a national level. As the Laender usually defend their areas of competence with great vigour against Brussels or Berlin, this was quite an extraordinary request and must be considered an important success for the policy of health targets. It is not only the Laender who have recognised the potential and value of health targets. The other big, and possibly most important, group of stakeholders in the German health system, the nongovernmental corporatist self-governing institutions, have arrived at the same conclusion. Motivated by the prevailing concern to counterbalance the still dominant influence of economics on health policy (and budgets), a working group called Medical Orientation in the Health System was established in November 1997. Its task was to discuss conceptual, 96

GERMANY

methodological, and political issues in pursuit of health targets expressed in terms of health outcomes. This working group was not organised as an official institution of the health system but by an association called Gesellschaft für Versicherungswissenschaft und -gestaltung (GVG).This rather research oriented Association for Social Security Policy and Research had been founded as early as 1947 as a forum where “the heterogeneous membership of the GVG could discuss substantial and sometimes controversial social–political issues of mutual interest, enabling those involved to reach consensus on the necessary future changes”. As the GVG describes itself, its main aim is “to research into the developments in the field of social security, and to be a constructive influence on social policy”. The importance of the GVG is shown particularly in its membership. This comprises institutions and individuals who actively contribute to shaping the social protection system in Germany, including health. Its members include statutory social insurance institutions, private life insurance, health insurance and long-term care insurance companies, healthcare providers including physicians, dentists and hospitals, labour unions and employees, the pharmaceutical industry as well as governmental bureaucrats and academic experts. In other words, the GVG can be considered as a mainly self-funded think-tank of important healthcare actors in Germany. The GVG working group on medical orientation was successful. It reached conclusions and presented results at a conference in May 2000 on Selection of Health and Healthcare Targets in Germany. The audience included the German Health Minister. The results included criteria and indicators as well as topics where consensus is essential. As to criteria and indicators for the selection of public health targets (the target group was the chronically ill population) the consensus reached is shown in Tables 7.1 and 7.2. There was an agreement that health targets be selected and weighted according to the following criteria: ●

●

●

the current incidence of diseases taking into account population development and age structure life-years lost, risk involved and level of mental suffering (quality of life) from the point of view of those affected and of the community avoidability (prevention) from the medical-scientific perspective and from the sociological perspective (acceptance and adoption of lifestyle changes) 97

HEALTH TARGETS IN EUROPE

Table 7.1 Criteria for the selection of the problems to be given priority attention Indicators Scale of the problem

Prevalence, incidence

Gravity of the problem

Premature death, risk of delayed complications, permanent dependence on life sustaining interventions, early retirement, restriction of quality of life (mobility, pain, cognitive skills, sensory skills, mood, capacity to live up to the social role)

Health policy relevance of the groups affected by the problem

Increased incidence of the problem in individual target groups of health policy such as age groups, socioeconomic groups, socially marginalised groups

Priority of the problem as rated by the population

Rate of persons seeing a doctor for the problem, willingness to pay

Resources expended on the problem so far

Treatment costs, investment costs, research costs

Possibility to involve patients and relatives in problem solving efforts

Readiness, competence, compliance

Table 7.2

Criteria for the selection of care targets Indicators

Availability of appropriate/adequate treatment options (capacities)

Regional service network density, staff, and equipment infrastructure

Case for improving any given traditional therapeutic strategy

Consensus and evidence-based recommendations from the technical societies, compliance, patient satisfaction

Case for improving hitherto practised organisational forms of care

Consensus and evidence-based recommendations from the technical societies, compliance, patient satisfaction, type and number of actors involved

Discrepancy in care between what complies with the guidelines and what is actually delivered

Dissemination of medical standards and their observance by care providers

98

GERMANY ● ● ● ● ● ● ● ●

rate of uptake of existing prevention options amenability to treatment in medical-scientific terms rate of uptake of existing treatment options direct costs of disease indirect costs of disease costs of disease prevention costs of attaining the health target reliability of the prioritisation as health target.

In weighting, care must be taken to ensure that targets concerned with the delivery of medical care of patients suffering from “priority” conditions do not disproportionately compromise the care of others. The intention is that the finite resources should benefit as many insured persons as possible. Finally, and most importantly, there was an agreement that the statutory health insurance system, including care providers/health insurances, pension insurance, accident insurance, private health insurances, and the public healthcare system, must seek to accomplish the following tasks by way of a consensus. ●

● ●

●

●

Identification and weighting of relevant selection criteria and indicators. Analysis of the full range of health problems. Analysis of health problems in terms of potential care provision deficits and policies to eliminate them. Precise formulation of care targets, where necessary (extent of improvement targets to be attained by a given point in time). Check on progress made as targets are implemented.

The result of the conference was an agreement that the work of the GVG should continue on a more formalised basis, as a necessary step in establishing health targets for Germany. This has provided a positive climate as well as the necessary political commitment.

The future Knowing what happened in the past, keeping in mind the difficulties to be overcome, and acknowledging the continuing conflicts of interest, it may be more than a little dangerous to make definite predictions as to 99

HEALTH TARGETS IN EUROPE

what will happen in the future and especially about when things will happen. But I believe there are sufficient reasons to be optimistic. As a result of the Berlin conference, the work of GVG was formalised and funded in a contract with the German Health Ministry. The GVG and the Ministry agreed on a programme for the definition and implementation of health and healthcare targets in order to achieve a consensus of all the relevant stakeholders on: ●

●

the creation of a realistic list of specific health targets as a proposal to be made to political decision makers the preparation of a strategy for the implementation of health targets.

The aim is to publish a final report by mid 2002 – not a long timespan. The Sachverständigenrat für die Konzertierte Aktion im Gesundheitswesen (Experts Council for Concerted Action) is a most important advisory body to the Health Ministry. It reports regularly on important matters and makes proposals for future government activities.The reports of this committee attract widespread public and media interest. In its latest report, one of the five chapters is to be dedicated to “a more targeted orientation of the health system”. In this publication the need for, and the potential of, health targets in the German health system will be set out in detail. The report will include descriptions of the experiences of other countries, the necessary data and indicators and health determinants for implementation and evaluation. I expect this report to end with a very clear and explicit proposal that health targets must be established as quickly as possible in Germany. These suggestions will not only trigger an even wider debate on health targets but will also be merged with the work of the GVG working group. The GVG, as a research based organisation, has over the past year established a programme to develop health targets specific to Germany’s needs and situation. As a result of the work of many groups and committees involving experts from different bodies and organisations, and following an analysis of health target strategies of various other countries, a list of possible health problems was drawn up. On the basis of these data a number of health targets will be selected. This so-called Zielekorb is divided into four sections: 1. relevance to clinical problems 2. prevention and health promotion 100

GERMANY

3. different age and population groups (for example children, women, the chronically ill, ethnic minorities) 4. emphasis on people and patients (for example equality, access). A list of roughly 200 health problems is now being prioritised in relation to the following 10 criteria. ● ● ● ● ● ● ● ● ●

●

Gravity of the problem Scale/dissemination of problem within population Potential for improvements Relevance for the political economy Ethical aspects Equal opportunities aspects Priority of the problem as rated by the population Potential to measure progress Implementation potential/availability of appropriate treatment options Opportunity for involvement of affected population group

The aim is to reduce this list of 200 items and to make sure that targets are equally distributed between all four sections of the Zielekorb. The result will be a proposal for a smaller number of targets in the autumn of 2001. It will then be up to the decision makers at the federal level to give these targets political relevance and backing. Consequently it is to be hoped that by the end of 2002 Germany will have a set of national health targets.

Conclusion Work on health targets in Germany has been going on at different organisational levels for about the last 15 years. Its success so far has been limited. Having learned from the experiences of the past the work is now developing on a much bigger scale. Nevertheless, it is still only preparatory work. A widespread political commitment to health targets is evident and not just from the scientific public health community but also from health policy decision makers at all political levels. The final test is still to come. Two important questions remain unanswered. ●

Who will decide the health targets: the Health Ministry, the government itself, the Parliament, the Concerted Action Group or a still to be created special conference of all concerned? 101

HEALTH TARGETS IN EUROPE ●

What will be the reaction of those stakeholders who believe that their own interests are not being sufficiently met by the targets?

In Germany there is a certain tendency to try to answer all questions before embarking on the work. In the case of health targeting, we will have to cross the bridges when we get there. At least we are finally getting closer to the river.

102

8: North Rhine-Westphalia BIRGIT WEIHRAUCH

Introduction In 1995 the North Rhine-Westphalia State Health Conference adopted 10 priority health targets. Thus North Rhine-Westphalia (NRW) became the first German state to be involved in a comprehensive, systematic, and rational process of health targeting.1–4 In Germany the topic of health targets had for a long time attracted little scientific attention. Only in recent years has it been considered as a concrete political concept. This contrasts with other countries, both within and without Europe, where, following the adoption of global health targets by the WHO in 1977, there has been intensive target setting activity and many target oriented policies. Targets are clearly helpful in drawing up health policies and motivating the relevant organisations and people. But only if targets are specific and explicitly formulated can they be used as political instruments for management and development. It can be assumed that the pluralistic, self-governing structure of Germany’s health system (see Chapter 7) has contributed to the fact that the introduction of health targeting has been relatively slow. The sharing of responsibilities between the federal government and the states – with most essential responsibilities lying with the states – has made what is inherently a complex process even more complex. Nonetheless, with its initiative of introducing health targeting, North Rhine-Westphalia was proactive in promoting discussions about the opportunities and limitations of targeting and in exploring the most feasible and constitutional way of proceeding in the light of Germany’s tradition of a self-negotiated health system. The development of target setting in North Rhine-Westphalia has to be seen against the background of the major efforts made since the beginning of the 1990s to shift health policy management, and organisational structure onto a new and rational basis in pursuit of 103

HEALTH TARGETS IN EUROPE

more transparency, effectiveness, and efficiency in handling scarce resources. The aim was to achieve continuing improvement of the health status of its present and future population. The state made a great effort to adopt the so-called “new public health” approach in NRW. For example, as a founding member of the WHO network Regions for Health it made great use of its membership to pursue and implement the WHO Health for All policy. An essential early step was the strengthening of public health sciences in the universities. The first faculty for public health sciences in Germany was founded at the University of Bielefeld in 1994. Other public health units were established and developed at the Universities of Cologne (1999), Düsseldorf (1991) and Münster (1993). Links were also established with equivalent public health bodies in other European countries. In 1995 the State Institute of Public Health North Rhine-Westphalia (loegd ) was established as an institution of the Health Ministry. It functions as a source of advice and support for the state government, as well as for the local level. The Health Ministry charged the loegd with the task of carrying out the operational work of health targeting, monitoring, and health reporting. In 1995, the Health Ministry of North Rhine-Westphalia initiated the founding of the European Public Health Centre (EPHZ). Its aim was to strengthen and speed up the transfer of knowledge between scientific research, policy, and practice. The convening of the state health conference in 1991 was a decisive step in the introduction of health targeting. Subsequently the initiation of local health conferences in the mid 1990s was of similar importance. These were the measures that established systematic procedures for participation and active involvement of the essential organisations and institutions of the self-governing health system. The aim was the implementation of the so-called health policy management cycle as a participating process for: ● ● ●

●

monitoring and analysing health data and information deriving and defining health targets developing and implementing the necessary strategies and measures evaluating and analysing outcomes.

Of course, we have not yet been able to uniformly achieve the ideal process of rational health policy making that this cycle suggests. But 104

NORTH RHINE-WESTPHALIA

we have, over the past years, taken a number of decisive steps towards achieving this ideal and the development of NRW’s particular approach to a target oriented health policy has contributed decisively to the development of health targets both in other German states and at the federal level.

State Health Conference in North Rhine-Westphalia In Germany’s pluralistic and self-governing healthcare system, the legal basis of the system is to a considerable extent determined by federal law – especially Social Code V. The states are, above all, endowed with responsibility for implementing this legislation and for managing the process. Comprehensive legislative competencies also lie with the states themselves. In this context it should be understood that, for historical reasons, the different branches of the social insurance system and the divisions of health care (health insurance, pension schemes, accident insurance, nursing care insurance, public health service, social assistance benefit) have often acted independently of one another. Therefore it became necessary to manage the process so as to establish common targets and achieve coordination and cooperation between the different health policy partners, each with its often differing and sometimes competing interests. Against this background the state of North Rhine-Westphalia established a structure for communication and cooperation. In 1991, the State Health Conference North Rhine-Westphalia was founded. As a consequence of the project for local coordination of health and social care (1995), corresponding structures were introduced at the local level. It is interesting to recall that the State Health Conference was founded on the occasion of a rather controversial discussion about the first State Health Report, published in 1991.This related to the contents as well as to the procedures employed in drawing up the report. The members of the health system, (especially the doctors’ organisations, health insurance funds, and the hospitals association) took the view that neither the development of the report nor the lessons to be drawn from it ought to be considered uniquely a matter for the state. The State Health Conference includes all organisations and institutions with responsibility for health care (see Box 8.1). In recent years representatives of the patients have also been included. The chair is taken personally by the Minister. 105

HEALTH TARGETS IN EUROPE

Box 8.1 Membership of the State Health Conference NRW ●

● ● ● ● ●

● ● ● ● ● ● ●

● ●

Chambers of physicians, dentists, pharmacists, and associations of the healthcare professions Associations of statutory health insurance physicians and dentists Health insurance funds Hospitals association of NRW Associations of charitable organisations Pension schemes (state insurance companies of the Rhineland and Westphalia-Lippe as well as the federal insurance company and the federal miners’ guild) Accident insurance German trade unions Employers’ associations Associations of cities and districts Regional associations of the Rhineland and Westphalia-Lippe Regional administrations Representatives of self-help organisations (organisations of the patients) State Institute of Public Health of NRW Ministry of Women,Youth, Family, and Health

Since its foundation, the annual State Health Conference has dealt with many complex and important topics, has adopted numerous joint resolutions, and has made concrete recommendations for a target oriented common course of action (see Box 8.2). It is crucial that all partners commit themselves to implementing these recommendations and to taking the commonly agreed steps in each of their areas of responsibility. The State Health Conference is supported by a preparatory committee, with subsidiary working groups established for special areas. This important body meets every 6–8 weeks and prepares the annual State Health Conference. It is concerned with the implementation of recommendations and deals with a variety of major topics and subjects of relevance to NRW’s health policy. The State Health Conference NRW has thus become an indispensable forum for discussion and decision making at state level and has led to a new culture of communication and coordination in North Rhine-Westphalia. The “management cycle” described above should be regarded as a principle of prime importance for the discussions, decisions, and implementation across the entire spectrum of health policy. 106

NORTH RHINE-WESTPHALIA

Box 8.2 Topics and resolutions of the State Health Conference NRW 1992 ● Outpatient psychiatric care ● Number of medical students and quality of medical training 1993 ● Environmental medicine 1994 ● Health promotion ● The consortium on “Healthy State of North Rhine-Westphalia” 1995 ● Ten priority health targets for NRW ● Continuing the health reform 1996 ● Quality assurance in an increasingly competition oriented health system ● Continuing health promotion and self-help activities with new accents 1997 ● The health system location factor as a driving force for employment ● Elaboration of models for further development of quality assurance in the health system 1998 ● Strengthening the role of citizens and patients in NRW’s health system 1999 Further development of telematics in health care ● Health for children and young people in NRW ●

2000 ● Health policy in Europe – developments, opportunities, and prospects from the point of view of the State of North Rhine-Westphalia 2001 ● Social conditions and health

Local health conferences With the introduction of the North Rhine-Westphalia pilot project on local coordination of health and social care, the developments at the state level were mirrored at the local level. The aim of this project (carried out between 1995 and 1998 in 28 out of 54 communities) was to establish corresponding practices and joint agreement and 107

HEALTH TARGETS IN EUROPE

planning at the local level. So-called “round tables” were set up in order to achieve more rational health care locally, based on a coordinated analysis of needs and plans and on agreement of common recommendations for action. From the beginning health monitoring and health reporting as well as common target setting procedures in the form of recommendations for action played an important role at the local level.The loegd together with a scientific institute gave technical support for the planning processes drawn up for special topics (so-called working and planning aids). At both the state and local levels the health conferences have become firmly incorporated into North Rhine-Westphalia’s Public Health Service Act, which came into force in 1998. In this way a process was launched which involved all 54 municipalities of North Rhine-Westphalia, in each of which a health conference was set up. The effects of this Act are being scientifically evaluated: here special interest lies with the local health conferences. More than 100 recommendations for action have been agreed at this local level and are in the process of implementation. Also the preparatory committee of the State Health Conference has from the beginning been intensively involved in the development process at the local level, not only because of overlapping responsibilities but also because of the need to guarantee compatibility of procedures. At the state level, and especially through the work of the Ministry and loegd, the processes are additionally supported by regularly holding workshops for the exchange of information and by a variety of supports for health monitoring and reporting. The processes of health monitoring and health reporting and the formulation of health targets have to be seen against this background. In Germany’s pluralistic self-governing health system, health reporting and target setting as a “state directive” would be quite ineffective.5

The targets and their functions The second State Health Conference (1993) initiated discussions on a target setting programme for North Rhine-Westphalia. The third State Health Conference (1994) adopted a major resolution on the function of health targets, the selection of topics, and the development of programmes. It specified that health targeting should: ●

108

encourage the interlocking of health policy with other areas of politics

NORTH RHINE-WESTPHALIA ●

● ●

define priorities for the development of long-term perspectives in health policy improve the controlling of the efficiency of employed resources establish a joint understanding among healthcare partners on the direction of health policy as a basis for cooperation.

The fourth State Health Conference (1995) adopted the following 10 priority health targets as a basis for North Rhine-Westphalia’s health policy.6 These were a selection taken from those in the 1985 WHO Health for All strategy. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

Reducing cardiovascular disease Controlling cancer Settings for health promotion Tobacco, alcohol, and psychoactive drugs Environmental health management Primary health care Hospital care Community services to meet special needs Health research and development Health information support

As a result of this process of cooperative target development, it should be possible to arrive at answers to both present and future urgent problems in the health system. The following examples come from the publication Ten Priority Health Targets for NRW 6 (author’s translation). ●

●

●

●

Necessity of a further improvement of health promotion and health care. Optimising the efficiency of all resources available, considering requirements and economy by implementing procedures of evaluation and outcome assessment. Further development of structures in the different areas of action and the organisations of the health system by stressing and implementing principles of integration, cooperation, communication, synergy, transparency, and opening up of the system. Implementation of competition oriented elements in areas where an increase of performance and innovation seems to be possible. 109

HEALTH TARGETS IN EUROPE ●

●

● ●

●

Implementation of consensual quality criteria for performances in health care as well as for measures of prevention and health promotion. Increased transparency of the services provided in health care for those who are affected. Improvement of patient information and consumer protection. Optimising cooperation between professionals and nonprofessionals in order to improve the situation for the sick and those who are affected. Promotion of participative approaches in decision making and implementation processes.

Although it was decided to model NRW’s health targets on the 38 WHO health targets, these were to be interpreted in terms of the epidemiology and social structures of North Rhine-Westphalia. Furthermore, in the process of concretely defining and implementing targets, regular feedback was given on parallel activities in health and other areas of state policy.7

Target areas The NRW health targets, like those of its WHO model, are related to all five major areas of health policy. ●

●

● ●

●

Achieving better health (target 1: reducing cardiovascular disease and target 2: controlling cancer). Lifestyles conducive to health (target 3: settings for health promotion and target 4: tobacco, alcohol, and psychoactive drugs). Healthy environment (target 5: environmental health management). Appropriate care (target 6: primary health care, target 7: hospital care and target 8: community services to meet special needs). Health for all development strategies (target 9: health research and development and target 10: health information support).

The NRW targets are related to the WHO’s three levels of action: orientation towards disease patterns; orientation towards health care; orientation towards methods and instruments. Cross-sectional issues were also considered in refining and implementing all 10 health targets. These addressed improvement in the care and condition of chronically sick and disabled people, and equity in health. More recently, other considerations have influenced the process; for 110

NORTH RHINE-WESTPHALIA

example, the topic “Strengthening the role of citizens and patients in NRW’s health system” (1998) included greater patient centredness, better health information, greater participation of patients in decision making, and strengthening patients’ rights.

The definition of targets The NRW programme follows the hierarchical structure of “targets”, “subtargets”, and “strategies” suggested by the WHO. We determined that targets must be firmly linked to the actors responsible for their implementation. (In this programme more than 120 individual measures are clearly specified and linked to the authorities with the responsibility for carrying them out, see page 112.) An NRW health target (text adopted in 1995) is structured as follows: ● ● ● ● ● ●

the target itself (corresponding to the WHO target) concretion (the planned strategies) background (of the problem) approach to solution (the intended development issues) relevant activities in North Rhine-Westphalia (already in process) preliminary selection of indicators (for monitoring and evaluation of results).

Each target was constructed with a 10 year timeframe (to 2005), though for some of the components shorter timeframes for implementation were agreed.

Quantification The question of whether and to what extent targets have to be quantified has led to intensive discussion and controversy at the international level over the last 20 years. In some cases it has been disillusioning to follow the process of developing quantitative targets. Nonetheless, the quantification of targets sharpens the focus on the achievement of targets and motivates evaluation of the process. In March 1996 the European Public Health Centre NRW (EPHZ) convened an international workshop in Brussels to discuss the question of quantification.8 As a result of these discussions some global quantified target figures were created for NRW (for example, in the implementation of target 2: controlling cancer). Greater emphasis 111

HEALTH TARGETS IN EUROPE

was given to the formulation of concrete strategies, with as far as possible, measurable outcome criteria. Nonetheless, in line with WHO concepts at that time, most of the targets formulated in 1995 relate to an improvement of structure and process variables.

Further consolidation and implementation From the outset, the 1995 target paper was not to be regarded as complete. Rather, it was intended to develop concepts for concretion and implementation of the 10 NRW targets in a step by step approach. Plans for target 10, concerned with health information support, were adopted by the State Health Conference. An introduction to evaluation and a manual with background information are in preparation. Despite progress with this and other targets, it had been decided to concentrate in the first instance on targets 2, 4, and 8, where good progress has been made. The State Health Conference established working groups, whose task was to clarify and define in detail: ● ● ● ●

steps to implementation links to the actors the schedule of activities quantification and development of evaluation.

Target 4, Part 1, was adopted as a joint initiative in November 1998 and was published as the “State programme against addiction”.9 In this first part the state programme deals with all cross-sectional questions of addiction (for example, prevention, target group orientation) as well as dependency on illegal drugs, alcohol, and pharmaceuticals (see page 111). The programme was agreed in detail with all the relevant actors in the healthcare system and with all the ministers of the state government. Part 2 of the target 4 programme was adopted in May 2001. Based on the further development of Part 1, it deals with dependency on tobacco and on non-substance based addictions like compulsive gambling. A working group is coordinating the implementation of Part 1 and Part 2 of the programme. It includes not only the professional stakeholders but also patient representatives and representatives of the self-help movement. 112

NORTH RHINE-WESTPHALIA

Target 2 (controlling cancer) has also been published as a manual.10,11 Again, the details were agreed with all partners in the healthcare system. It specified the following six subtargets and linked these to the strategies necessary for implementation. ●

●

● ●

●

●

Subtarget 1: intensifying networking and cooperation in combating cancer. Subtarget 2: further development of epidemiology and monitoring of cancer. Subtarget 3: strengthening prevention of cancer. Subtarget 4: improvement and intensifying the early detection of cancer. Subtarget 5: integrating psychosocial advice and self-help support in a comprehensive concept for care. Subtarget 6: facilitating the humane care of critically ill and dying people.

Evaluation and monitoring There are plans to evaluate the entire health target programme in North Rhine-Westphalia, beginning with the evaluation of targets 2 and 4. A comprehensive approach has been adopted by the preparatory committee and will now be the basis for further steps.12 A crucial problem in evaluating programmes is, of course, the considerable difficulty of demonstrating a causal link between the interventions carried out and the subsequent changes in health statistics. In the longer term, it will be crucial to develop evaluative methods that can demonstrate a reliable connection between causes and effects. North Rhine-Westphalia hopes to contribute to this development, by engaging with other health target programme researchers in other regions.13

Provisional results The experience so far in North Rhine-Westphalia has been that the process of targeting, apart from the primary intention of the targets in terms of health gain, has been of substantial benefit to the functioning of the health system. Interprofessional and intersectoral discussions have brought potential partners together, as a result of which joint initiatives have been agreed. For example, in the work on target 4, it proved possible to achieve a fundamental agreement on drug policy. 113

HEALTH TARGETS IN EUROPE

The definition of joint health targets leads to a number of opportunities and benefits for all the partners involved. Some results are: ● ●

●

●

●

●

● ●

more rational actions in health policy agreement among health policy partners (with sometimes conflicting interests) aimed at a common understanding and joint priorities strengthening democratic discussion and decision making which also involves patients greater transparency of action for all parties involved (in particular for patients) reinforcing the long-term aspect of a course of action (in comparison with a preoccupation with daily routines which are often ephemeral in nature) increased accountability in terms of evaluation, monitoring, and health outcome realising an evidence-based quality management system reinforcing the implementation of necessary measures in the existing system.

Prerequisites However, if such positive effects are to be achieved, there are certain prerequisites. ●

● ●

● ● ●

●

A structured and disciplined procedure: the process must not be characterised by the spontaneity of actors and the discretionary determination of interest. An orientation towards scientific findings. A realistic and pragmatic approach when defining targets by taking account of pre-existing programmes. Clearly defined periods of time for the implementation process. Clear assignment of responsibilities for implementing the targets. Clarification of questions concerning the allocation of resources linked to the implementation process. Evaluation of outcomes with a good balance between short-term and long-term periods of review.

Prospects and further planning The German health system, like every other system worldwide, is confronted with growing expectations and challenges, on the one hand, 114

NORTH RHINE-WESTPHALIA

and limited resources on the other. An evidence-based healthcare system aims, among other things, to promote the use of healthcare resources to greatest effect.The introduction of health targets in pursuit of this is not without problems: expectations are raised and this creates new priorities. Hence, new “priorities” create new “posteriorities”.This may not mean and does not justify a discussion about rationing and privatising of the provision of services. Rather, with more rationality in the use of resources, greater reserves in the economy can be mobilised. There is currently intense interest in health targeting not only at the NRW state level, but at local level also. Discussions are being held on how the targeting process at the level of the cities and districts can be optimised. This includes not only the question of how state health targets can be translated into targets at local level, but also how targets primarily identified in terms of local needs can be given due emphasis. On the initiative of North Rhine-Westphalia, the 1999 Health Ministers’ Conference unanimously adopted a resolution on the rationale and necessity of target setting at the federal level. Other laender have already entered corresponding discussions or have already adopted state health targets. In fact, the most exciting developments are now taking place at the federal level. On instruction from the federal government, and after two years of discussion by an expert committee (established by the Gesellschaft für Versicherungswissenschaft undgestaltung – GVG), a participative health target setting process similar to that in North Rhine-Westphalia has been initiated. This involves all partners in Germany’s self-governing health system, including representatives of the citizens and patients. North Rhine-Westphalia has, during the past two years, actively participated in these preparatory discussions. As far as cross-sectional responsibilities are concerned, what is now needed is the development of compatible procedures at the levels of federal, state, and local policy. And with the growing importance accorded to health policy, discussions will also be necessary about target setting at the European level, and these will need to correspond to the existing procedures in the member states. References 1 Sendler H. Gesundheitsziele tragfähig verabreden. Erfahrungen aus der Praxis in NRW. Gesellschaftspolitische Kommentare. Sonderausgabe 1999;2:7–9. 2 Weihrauch B.Target-setting in North Rhine-Westphalia, Germany. Health Targets: News & Views 2000;3:6. 3 Weihrauch B. Health targets as a means of a rational health policy in North Rhine-Westphalia. Eur J Public Health 2000;10:34–7. 115

HEALTH TARGETS IN EUROPE

4 Ministerium für Frauen, Jugend, Familie und Gesundheit des Landes Nordrhein-Westfalen. Zehn vorrangige Gesundheitsziele für NRW – Gesundheitspolitisches Konzept. Düsseldorf, Bielefeld, 2000. 5 Welteke R,Weihrauch B. Zehn vorrangige Gesundheitziele für NordrheinWestfalen – ein Situationsbericht. In: Bergmann KE, Baier B, Meinlschmidt G, eds. Gesundheitsziele für Berlin. Wissenschaftliche Grundlagen und epidemiologisch begründete Vorschläge. Berlin: Verlag Walter de Gruyter, 1996:148–54. 6 Ministerium für Arbeit, Gesundheit und Soziales des Landes NordrheinWestfalen. Zehn vorrangige Gesundheitziele für NRW. Grundlagen für die nordrhein-westfälische Gesundheitspolitik. Düsseldorf: Bielefeld, 1995. 7 Welteke R, Menke R, Brand H. Das NRW-Gesundheitszielkonzept im europischen und internationalen Vergleich. In: Geene R, Luber E, eds. Gesundheitsziele. Planung in der Gesundheitspolitik. Frankfurt am Main: Marbuse-Verlag, 2000:91–106. 8 International Workshop on Target Setting in Brussels, 8–9 March 1996. European Public Health Centre, NRW. 9 Ministerium für Frauen, Jugend, Familie und Gesundheit des Landes Nordrhein-Westfalen. NRW-Landesprogramm gegen Sucht. Eine Gemeinschaftsinitiative in Umsetzung des Ziels 4 der Zehn vorrangigen Gesundheitsziele für NRW (Landesgesundheitskonferenz 1995). Düsseldorf 1999. 10 Materialienband zu Gesundheitsziel 2 Krebs bekämpfen. Veröffentlichung vorgesehen für 2001. 11 Ministerium für Frauen, Jugend, Familie und Gesundheit des Landes Nordrhein-Westfalen. Zehn vorrangige Gesundheitsziele für NRW. Ziel 2: Krebs bekämpfen. Teilziele, Strategien, Mafßlnahmen. Eine Gemeinschaftsinitiative in Umsetzung des Ziels 2 der Zehn vorrangigen Gesundheitsziele für NRW (Landesgesundheitskonferenz 1995). Düsseldorf, Bielefeld, 2000. 12 Evaluationskonzept zum nordrhein-westfälischen Gesundheitsprogramm Veröffentlichung vorgesehen für 2001. 13 Welteke R, Brand H. Gesundheitsberichterstattung und Gesundheitsziele. Gesundheitswesen 1999;61:340–5.

116

9: Finland SEPPO V KOSKINEN AND TAPANI A MELKAS

Introduction There are 5.2 million inhabitants in Finland at the beginning of the 21st century. The total area of the country is among the largest in Europe (338 000 sq km) and half of the population lives in the five southwestern regions covering only 14% of the land area. In contrast, less than 4% of Finns live in the northern third of the country which has on average only two inhabitants per sq km. Children aged under 15 account for 18% of the total Finnish population and over-65s account for 15%. At present the proportion of elderly people is slightly smaller than in most other west European countries but this is estimated to grow rapidly, reaching 22.5% by the year 2020 when the postwar baby boom generation will have reached retirement age. In Finland, the organisation and financing of welfare services and preventive work has been considered a public responsibility for a long time. The main responsibility for arranging services lies with the 448 municipalities. The state determines the general guidelines and directs the service system at the national level. Most municipalities are very small, with populations of less than 5000 in over half of them. This small size sometimes causes problems because small units tend to suffer from limited financial resources and insufficient expertise necessary for developing the welfare system. However, municipalities cooperate in the provision of services and this is particularly common among the smallest communities. Finnish health policy is aimed at reducing diseases and premature deaths, extending the active and healthy life of people, ensuring the best possible quality of life for all, and reducing differences in health between different sectors of the population. There is an expectation that the dimension of health will be emphasised in all aspects of public decision making. Finnish health policy relies both on efficient and accessible healthcare services, available to the entire population, and on broadly based health promotion. 117

HEALTH TARGETS IN EUROPE

Health in Finland The health of the population in Finland has improved significantly during the past decades. The major causes of premature mortality are cardiovascular diseases, cancer, accidents, suicides, and chronic lung disease. With the single exception of suicides, premature mortality from all these causes has fallen significantly during the past 30 years. Cardiovascular mortality approaches the average west European level and cancer mortality is now lower in Finland than in any other European country. Infant mortality has been among the lowest in the world for more than two decades and it has continued declining, reaching the level of 3.6/1000 in 1999. As a consequence, life expectancy at birth has rapidly increased. In the early 1970s, male life expectancy was only 66–67 years, shorter than in any other west European country and as much as 5.5 years less than in Sweden (which has the longest life expectancy in Europe). By 1999, the life expectancy of Finnish men had increased to 73.7 years, approaching the average for all EU countries and lagging only three years behind the Swedish figure. During the same period, the life expectancy of Finnish women has climbed from the average to one of the best west European levels (81 years in 1999). The improvement of public health is also indicated by the decreasing incidence of many common diseases, a reduction in the prevalence of many functional disabilities, and a growing proportion of people regarding their health as good. The improvements we have seen are the net result of many changes in national life. Living conditions have become healthier and positive developments can also be seen in lifestyles, exemplified particularly by the improvement in eating habits and a rapid reduction of smoking among men. Moreover, people have better access to increasingly effective healthcare services. However, there is still much room for improvement and there are also certain worrying trends and unsolved problems. New threats to public health are on the horizon: asthma, allergies, diabetes, and drug abuse have clearly increased. There is also some evidence of an increase in mental disorders and musculoskeletal diseases, although truly reliable trend data are lacking. Sociodemographic disparities in health remain an important public health problem in Finland. These have so far been rather resistant to health policy efforts. In the eastern and northern regions, life expectancy of men is about four years (and in women about two years) shorter than those in the more advantaged western regions. Also 118

FINLAND

morbidity continues to be higher in eastern and northern Finland than in the west and south. These regional differences in mortality are primarily explained by cardiovascular diseases, but similar patterns are also seen in other causes of death. There is some suggestion of a reduction in the east–west disparities in health but the evidence is relatively weak. In 1999, life expectancy of Finnish males was 7.3 years less than that of women. This is an exceptionally wide margin in western Europe, even though there has been a reduction of more than one year in the disparity since the late 1970s. People with higher levels of education and higher social status may expect to live longer than those who have a low level of education and social status. In the early half of the 1990s, the difference in life expectancy for men at the age of 35 between the highest and the lowest social groups had increased to about six years. Among women of the same age it had increased to about three years. In the early 1980s the difference was about five years for men and two years for women. In addition to new and increasing health problems and the persistent or even widening health disparities, there are further major challenges to health policy in Finland: the ageing of the population, changing needs and expectations, and problems in financing health care and health promotion.1,2

Changes in planning and management of health policy Since the late 19th century the provision of health care in Finland has increasingly been the responsibility of municipalities. The 1972 Primary Health Care Act obliged municipalities to run health centres for primary health care and health promotion and since the 1950s nearly all hospitals providing specialised care have been owned by individual municipalities or by municipal federations. Despite the vital role of the municipalities in the actual provision of services, the Finnish health system was under strong centralised control until the mid 1980s. Municipalities had and still have considerable autonomy based on municipal tax, but their social and health care was strictly directed by national norms and economic controls. Detailed norms for activities were issued by the National Board of Health. There were subsidies for social and health care and resources were allocated according to a national planning system. 119

HEALTH TARGETS IN EUROPE

State subsidies were only paid for investments and personnel that had been specified in the national plan – which was adopted annually by central government and implemented by the state provincial administration. Municipalities had an opportunity to run activities outside the national plan but this had to be totally at their own expense. Such activities were unusual because the level of the state subsidy was rather high, ranging from 30% to 70% of the expenditures. In the late 1980s and early 1990s, a marked step by step decentralisation reshaped the Finnish public administration, including the health sector. The possibility of setting national norms was gradually diminished and eventually the National Board of Health became a research and development institution, with no administrative responsibilities. The system of national annual planning ceased and state subsidies were paid on the basis of the economic, demographic, and geographic features of the municipality. Because of the concurrent economic depression, the level of state subsidies decreased sharply. Within the Ministry of Social Affairs and Health, reorganisation resulted in two separate departments for health, one for health and social services and the other for the promotion of health and welfare. A national intersectoral public health committee was established and biennial public health reports to Parliament were initiated. These changes in the planning and management system shifted the emphasis in the use of targets as an instrument of health policy. In the earlier centralised system, a strict hierarchy of targets and the means to achieve them was appropriate. This meant that the responsibilities of actors at all levels could be precisely specified. In the present decentralised system, where the number of more or less autonomous actors is high (both in the health sector and outside it) the role of targets and the requirements for them are different. There is a new emphasis on creating commitment and building consensus.

Experiences from the 1980s and 1990s In Finland, precise health targets have had a relatively small role in national health policy.3 In the early 1980s, setting exact outcome targets was experimented with but the experiences were discouraging. For example, in 1983 the Advisory Committee for Health Education published a general plan for the development of health education,4 including numerous quantitative targets. Most of the targets were not achieved and in some cases the outcomes were the diametric opposite 120

FINLAND

of what had been aimed at. For example, according to one target alcohol mortality was to decline 20% by 1988. The observed change was a 30% increase in men and a 70% increase in women. In the case of a target on reduction of smoking there was a smaller discrepancy between the target and the actual development: a 3% annual decrease in tobacco consumption was expected and a 1% annual decrease was observed. However, in some other cases the targets were achieved: teenage abortions and the prevalence of dental caries declined in the anticipated way. In general, this kind of targeting did not prove to be very useful. The targets did not stimulate much effective action or create real commitment. Indeed, targets which proved to be unrealistic perhaps even reduced the credibility of the general project. A common conclusion reached by health policy makers was that if targets are to be set they must be backed by an effective programme of action, one that can realistically be expected to work and lead to the desired outcome. Modest role of targets in Finnish HFA 2000 strategy The Finnish HFA 2000 strategy document5 had four general aims: adding years to life, adding health to life, adding life to years, and reducing health disparities between population groups. Subordinate to these main goals, the programme included some 15 quantitative targets concerning, for example, life expectancy, mortality, dental health, and health behaviour. These quantitative health targets were not, however, essential cornerstones of the strategy. Rather, they served as examples to illustrate the general aims of the strategy. The targets were largely designed to assess the impact of the policy measures outlined in the strategy document. Their main role was to indicate the anticipated effects of planned policy, not to guide policy. During the preparatory process, the potential use of the 38 targets proposed by the WHO European Office6 was considered. These were regarded as scientifically based but too numerous and detailed and likely to inspire public health experts more than they would inspire political decision makers and the public. Since many of the proposed quantitative targets were not considered relevant to Finland, efforts to modify them did not seem useful. Instead the conclusion reached was to give the main emphasis to determining the direction of policies and to securing a broad commitment to them. In 1988, a thorough evaluation of the national HFA programme was considered necessary in order to take into account the experiences 121

HEALTH TARGETS IN EUROPE

accrued and to amend the programme which had already been in force for three years. Furthermore, the Finnish health system was facing significant changes which also had to be taken into account in the national HFA strategy. In 1981 Finland had already agreed with the WHO to act as a pioneer country in the HFA 2000 strategy, so it was therefore natural to ask the WHO to prepare the evaluation. An international evaluation group was convened in 1989 and its report was published in 1991.7 The evaluation group noted that quantitative health targets had been given a smaller role in the Finnish strategy than in the regional WHO documents. The group recommended that the role of target setting should be reassessed. It suggested that quantitative targets might encourage the scientific community to pay more attention to the key health questions and to be more active in producing the information necessary for intersectoral collaboration. In addition, quantitative targets would enhance the assessment of the impacts of the programme. For example, in terms of the difficult task of reducing health inequities, it might be very useful to set exact targets and define explicitly the measures needed to achieve them. The intersectoral steering committee of the Finnish HFA 2000 programme started revising the programme immediately after the evaluation report had been published. A draft version was widely circulated in 1992 and the ensuing comments were taken into account in finalising the document. In December 1992, the government approved the reformulated national strategy document which was published in 1993.8 In the revised strategy document, the main emphasis was given to prioritisation, the commitment of a broad spectrum of actors, and the promotion of public participation. These changes were in line with the recommendations of the international evaluation group. Seven fields were distinguished where, according to both national and international evaluations, new efforts were particularly needed.These fields included reducing health inequities, improving the functional capacity of the population, and collaboration in support of a preventive health policy. In each field the major challenges were identified and between six and 16 more or less explicit measures were defined. Furthermore, for each measure the revised programme defined the organisation or body with principal responsibility for implementation, as well as defining other bodies with an important collaborative role. Contrary to the recommendation of the international evaluation group, the revised strategy did not include a single quantitative health 122

FINLAND

outcome target. The aims were expressed in qualitative terms: for example, a reduction of health disparities between population groups and an improvement of functional capacity of the population. According to the vice chairman of the steering committee, “After a thorough reconsideration of the matter, in the light of recommendations from the external review group, the steering committee agreed to focus targets on action and not on numbers”.3 In the period during which the HFA policy has been pursued in Finland, most health indicators have developed favourably. Most of the outcome targets set in the original Finnish HFA strategy have been achieved. For instance, the decline in cardiovascular mortality has even been faster than was foreseen in the target launched in 1986 and the development of dental health has been more favourable than was anticipated. Significant progress has also been made with many major public health problems for which no quantitative targets were set. Examples include marked decreases in elderly mortality, work disability, and functional disability. Positive experiences from focused programmes There are also examples of the successful use of quantitative targets. In the early 1990s, a parliamentary committee proposed a target to halve traffic deaths over a period of 10 years.The government adopted this target as well as a multisectoral programme designed to achieve it and the programme was regularly revised in the light of follow up.The measures were initially unpopular and expensive but then enjoyed a high level of commitment as well as public support. During its latter years the commitment declined, but the target was almost achieved and deaths decreased from 734 in 1989 to 427 in 1999. This target was successfully implemented because it was realistic, backed by a detailed action programme, and supported by many actors. Further, they were motivated by the fact that the observed trend followed closely that predicted in the original target plan.

The beginning of the 21st century Reassessment of the role of targets in health policy The strong trend to decentralisation of health governance in Finland during the late 1980s and 1990s made it necessary to reconsider the previously quite negative attitude towards quantitative health outcome targets in Finland. Now that the central government could 123

HEALTH TARGETS IN EUROPE

no longer use financial incentives to direct operational health policy, outcome targets could provide an important new way of influencing the multitude of actors in the health field. Internationally, health targeting has received growing attention and this has put pressure on the architects of the Finnish health policy to reconsider the role of targets in Finland. National as well as foreign experiences have suggested that sometimes measurable health outcome targets can be useful in raising public awareness, creating commitment, and providing criteria for evaluation. On the other hand, some experiences have pointed in the opposite direction. Targets which are inappropriate in their quantity or content may even have negative effects on public health. This can happen by giving emphasis to measurable instead of to important health phenomena or by creating a distrust of health policy because the targets set seemed to be totally unrealistic. In the late 1990s, the Finnish Public Health Committee analysed 12 recent national programmes aimed at reducing major public health problems. The programme on traffic accidents appeared to be quite exceptional among the 12 in having a quantitative outcome target which strongly influenced the building, implementation, evaluation, and reformulation of the programme. Quantitative targets had been set in very few other programmes. Also predictions of the effects of programmes were rare. Consequently, evaluation and revision proved to be difficult. All of this has raised serious questions in Finland, not only about how to distinguish good targets from poor ones but also about whether health targeting should have a role in Finnish health policy. In 1999 the National Public Health Committee set out its criteria for well designed health targets. These stated that useful health targets should: ●

●

●

●

124

not be too numerous, in order to emphasise the importance of each target be wide enough to cover major public health problems and facilitate action over a wide area and should not focus on specific narrow problems just because progress on them can easily be measured be realistic, easily understandable and appreciated by the public and the politicians in order to remain credible and retain wide commitment lend themselves to evaluation and measurement using a generally accepted method

FINLAND ● ●

be formulated in partnership with the key implementers be provided with process targets in order to show how the health outcome targets are to be achieved.

Targets in the new Finnish HFA programme The Finnish government adopted a new intersectoral health programme in spring 2001.9 The programme is a continuation of the national HFA 2000 programme and is the Finnish response to the WHO’s Health 21.10 It includes the following eight main targets. 1. Child well-being and health will increase, and symptoms and diseases caused by insecurity will decrease appreciably. 2. Smoking by young people will decrease, to less than 15% of those aged 16–18; health problems associated with alcohol and drug use among the young will be dealt with appropriately and will not exceed the level of the early 1990s. 3. Accidental and violent death among young adult men will be cut by a third of the level during the late 1990s. 4. Working and functional capacity among people of working age and working conditions will improve, helping people to cope longer in working life; retirement will be about three years later than in 2000. 5. Average functional capacity among people over 75 will continue to improve as it has during the last 20 years. 6. Finns can expect to remain healthy for an average of two years longer than in 2000. 7. Finnish satisfaction with health service availability and functioning, and subjective healthiness and experiences of environment impacts on personal health will remain at least at the present level. 8. In implementing these targets, another aim will be to reduce inequality and increase the welfare and relative status of those population groups in the weakest position.The objective will then be to reduce mortality differences between the genders, groups with different educational backgrounds, and different vocational groupings by a fifth. The first five targets are age specific and the remainder are set for the whole population. They are all anchored in both political and 125

HEALTH TARGETS IN EUROPE

scientific thinking. They all reflect issues which have been at the core of political discussions on health in Finland during the last few years, among both experts and the general public. They cover large and essential parts of people’s health and will significantly improve the population’s health if the targets are achieved. Physical, mental, and social dimensions of health are included, as well as the subjective experiences of people. The first target is very broad and only defines in what direction child health should develop. The other seven targets express quantitatively where we should be in 2015. In addition to these targets, there are 36 policy guidelines which are designed to support their achievement. Some are measures relating directly to a single target, others promote the programme more generally. We can now estimate how far these targets conform to the criteria given earlier, which were formulated by the National Public Health Committee. Eight is not a very large number of targets and this means that none of them can be considered as secondary or insignificant. The national HFA 2000 programme launched in 1986 included only four general aims, but they were supplemented with numerous more specific subordinate targets. Also, with a set of only eight targets, it should be possible to achieve a widely based and strong commitment. Some of these new targets are constructed from smaller component targets, so that in fact the total number of separate targets is somewhat larger than eight. However, these composite targets are all concerned with a single issue, so that the components can best be seen as multiple indicators by which to measure their progress. For example, in the case of target 2 there needs to be a decrease of substance dependence among young people and this will require large general measures: positive developments in levels of tobacco, alcohol, and drug use are all essential parts of the desired trend. Most targets are broad enough to cover the major public health problems and facilitate action over a wide area. At first sight targets 2 and 3 seem to be the narrowest. However, substance dependence among young people is closely connected with a generally health endangering lifestyle. It largely determines young people’s physical and mental health, in both the short and long term. Mortality from accidents and violence among young adult men is also not an isolated problem in itself but also an indicator of risk taking behaviour in general and an unhealthy male culture which has wide ranging consequences for both male and female health. 126

FINLAND

For the most part the new targets can be easily understood by lay people and politicians, although some differences in their interpretation may nevertheless emerge. For example, the well-being and the insecurity of children can be understood in different ways. Lay people and specialists may mean different things when they speak about “healthy life expectancy” or “functional capacity”. However, major discrepancies in understanding the targets are not expected. It is also likely that lay people and politicians will regard the targets as realistic and achievable. Specialists are probably more suspicious of them, particularly as recent trends are not going in the direction predicated in targets 1, 2, and 8. Most of the targets can be measured and evaluated by several well established indicators. For target 1 (concerning child health) more appropriate measurement methods need to be developed. In target 4 (concerning working capacity) evaluation is not straightforward because even if functional capacity and workplace conditions were to improve, other factors may prevent the achievement of the target. Hundreds of people have participated in the planning process of the new health programme and the targets included in it. The drafts have been actively distributed for comment and the work finalised in the intersectoral National Public Health Committee and adopted by the government. For many of the targets the number of people involved in implementation is quite high. However, because of the thorough preparatory work, the key actors at least seem to have been strongly involved in their formulation. During the preparation of the programme in the intersectoral National Public Health Committee, its subcommittees, and in the numerous seminars organised by the committee, extensive discussion of the steps to be taken in order to achieve the desired outcomes has taken place. In the documentation so far, however, the outcome targets have not yet been related to the necessary process targets.This will be done, on the basis of the earlier preparatory discussions, during the implementation process and the process targets will be cooperatively formulated between the various actors in the different sectors and coordinated by the Public Health Committee.

Conclusion Quantitative health outcome targets have so far had a rather marginal role in Finnish health policy. When numerical health outcome targets have been set, they have generally only served as examples in relation 127

HEALTH TARGETS IN EUROPE

to qualitative targets or to illustrate the general policy aims.They have been used to demonstrate the anticipated effects of planned policy measures, rather than as the starting point for policy. The aims of health policy have usually been stated as qualitative outcome targets defining the prioritised areas in public health and indicating the direction in which we should proceed. Despite the justified reservations about quantitative health targets, some numerical outcome targets have been given a central role in the new national public health programme, Health 2015.9 The decentralisation in the planning and management system, as well as some national and international experiences, have led to a reconsideration of health outcome targets as instruments of health policy. In our previously centralised planning system the responsibilities and resources at all levels of the health and social sector could be stated exactly. Qualitative health outcome targets were then considered appropriate. Targets such as a decline in the prevalence of major diseases provided a sufficient basis for developing health policy measures, i.e. deciding what should be done, where, when, by whom, and with what resources. Further, qualitative outcome targets did not require the comprehensive information needed for setting realistic quantitative outcome targets. Nor did they entail the risk of only emphasising what is measurable and sacrificing, as a consequence, what is important. Qualitative outcome targets were considered a sufficient basis for deciding “what will be done, by whom, with what resources and within what timeframe – which is what policy making is all about”.3 In the present decentralised system with a high number of autonomous actors both in the health sector and in other sectors, creating commitment and building consensus will have to be emphasised. Targets should lead to work in multiple sectors and with many actors. In this context the role of easily understandable health outcome targets becomes important. They fix priorities, make results understandable and visible for decision makers and the public, give a basis for follow up and evaluation, and create commitment. Process targets are subordinate to the outcome targets and are largely formulated by the different, and relatively autonomous, actors. Nationally set process targets are now needed mainly in order to meet the challenges of intersectoral cooperation. An effort has been made to take into account the lessons learnt from both positive and negative experiences, in the formulation of the new Finnish health targets. It remains to be seen whether these turn 128

FINLAND

out to be realistic and whether they succeed in what is their main purpose – to create commitment and effective action among the various actors in the health sector and beyond. References 1 Aromaa A, Koskinen S, Huttunen J, eds. Health in Finland. Helsinki: National Public Health Institute and Ministry of Social Affairs and Health, 1999. 2 Statistical yearbook of Finland 2000. Helsinki: Statistics Finland, 2000. 3 Leppo K. Health for all policy in a pilot country: the case of Finland. In: Harrington P, Ritsatakis A, eds. European health policy conference: opportunities for the future, vol III. Copenhagen: WHO, 1995:70–82. 4 National Board of Health. General plan for the development of health education for 1984–88. Recommendation of the advisory committee for health education. Helsinki: National Board of Health, 1983. 5 Ministry of Social Affairs and Health. Health for all by the year 2000 – the Finnish national strategy. Helsinki: Ministry of Social Affairs and Health, 1987. 6 WHO Regional Office for Europe. Targets for health for all. Copenhagen: WHO, 1985. 7 WHO Regional Office for Europe. Health for all policy in Finland. Copenhagen: WHO, 1991. 8 Ministry of Social Affairs and Health. Health for all by the year 2000. Revised strategy for co-operation. Helsinki: Ministry of Social Affairs and Health, 1993. 9 Ministry of Social Affairs and Health. Government resolution on the health 2015 public health programme. Helsinki: Ministry of Social Affairs and Health, 2001:6. 10 WHO Regional Office for Europe. Health 21 – health for all in the 21st century. Copenhagen: WHO, 1999.

129

10: Italy GEORGE FRANCE

Introduction Italy adopted health targets (HTs) in 1998 and central government documents published since then have reiterated commitment to this strategy. In this chapter I will suggest that adoption of HTs is to be considered quite an exceptional event in health policy making in Italy; the HT strategy has a number of features which distinguish it from run-of-the-mill policy making. I will also suggest, however, that the HT strategy has encountered problems which are common to health policy in general. I begin with a description of the Italian HT strategy and consider some key features of the Italian system of governance; that is, the context in which health policy is designed and implemented. I will go on to identify some distinguishing characteristics of health policy making in Italy and explain why the HT strategy may be a “special event” for health policy. Finally I propose to examine a number of factors which may mean that HT policy – at least in some respects – is “business as usual” for the Italian health policy process.

The Italian policy for health targets Italy formally adopted HTs in 1998 with the publication of the National Health Plan 1998–2000.1 This document shifted the emphasis from health care to health; in the main, the focus was on disease prevention and health promotion as a more effective way of securing important improvements in health care while, of course, recognising that further progress in treatment, care, and rehabilitation is essential. The first of the two parts of the plan described a strategy for the pursuit of health in the widest meaning of that word and for the reduction of health inequalities. The plan selected five key (priority) areas for action, emphasising risk factors and lifestyle, disease groups, and social groups. National targets are specified for each of those, for 130

ITALY

a total of 100 targets. Box 10.1 gives an abbreviated list of the main targets. The five priority areas were: ● ● ● ● ●

promote healthy behaviour and lifestyles combat major diseases like cancer and cardiovascular illness improve the environment protect vulnerable groups upgrade the Italian healthcare system to European standards.

Box 10.1 Italian national health targets (National Health Plan 1998–2000, abbreviated list)2 Reproduced with permission of Oxford University Press 1. PROMOTE HEALTHY BEHAVIOUR AND LIFESTYLES Nutrition ● Reduce caloric intake from fat ● Increase carbohydrate caloric intake ● Reduce obesity Tobacco ● Reduce prevalence of smokers by 40% Alcohol ● Reduce prevalence of drinkers by 20% Physical exercise ● Increase prevalence of exercise by 10% 2. COMBAT MAJOR DISEASES Cardiovascular and cerebrovascular diseases ● Reduce mortality from heart disease and stroke by at least 10% ● Reduce inequalities in mortality among geographic areas and social groups ● Increase quality of life Tumours ● Reduce cancer deaths by at least 10% (men) and 5%

(women) focusing on lung, breast, stomach, cervical, and colorectal cancer ● Reduce inequalities in incidence, survival, and mortality among social classes ● Improve quality of life Infectious diseases ● Vaccinate 95% of children  24 mos for polio, diphtheria, tetanus, measles, rubella, mumps, whooping cough, hepatitis B, haemophilus influenza ● Coverage for flu vaccination up to 75% of the elderly ● Eradicate polio virus ● Extend vaccination coverage to immigrants ● Reduce hospital infections by 25%, focusing on UTI, surgical infections, pneumonia and catheter related infections ● Monitor outcome of TB treatment, completing 85% of treatments Accidents and occupational diseases ● Reduce mortality due to road accidents by 20% 131

HEALTH TARGETS IN EUROPE ●

●

●

Reduce the number of domestic accidents by 10% Reduce the number of work accidents by 10% Reduce the number of occupational diseases

3. IMPROVE THE ENVIRONMENT Air ● Reduce air pollution Water ● Ensure adequate supply of drinking water Nutrition ● Increase the safety of foods Radiation ● Reduce the risk of exposure to radioactivity ● Reduce exposure to sun’s ultraviolet rays Waste ● Increase the safety of waste disposal 4. PROTECT VULNERABLE GROUPS Immigrants ● Guarantee equal access to health services ● Extend vaccination coverage Drug and alcohol dependency ● Reduce mortality and morbidity ● Increase effectiveness of rehabilitation programmes Mental health ● Improve quality of life and social integration ● Reduce suicides Child and family health ● Reduce infant mortality ● Reduce risky behaviour in adolescents ● Adopt policies supporting families 132

Elderly ● Prevent disability and dependency ● Support families ● Integrate health and social services Terminally ill ● Promote and support voluntary organisations ● Increase home and hospice care 5. UPGRADE THE ITALIAN HEALTH SYSTEM TO EUROPEAN STANDARDS Transplants ● Increase organ donations ● Reduce the number of transplants performed abroad ● Increase survival and quality of life Rehabilitation ● Guarantee continuity of care Technological innovations ● Improve adoption of new technologies Rare disorders ● Early diagnosis and prompt referral to specialist centres Blood safety ● Increase donation ● Diffuse self-donation Health information systems ● Develop outcome oriented systems ● Integrate health information systems ● Improve data collection Veterinary medicine ● Develop cooperation at the EU level ● Promote accreditation of services and facilities

ITALY

The priority areas were selected because they cover significant causes of premature death and poor health and/or marked geographical and social class inequalities and because there is evidence of the impact of health promotion policies and disease prevention programmes. The plan’s subtitle was: A solidarity pact for health. The term “pact” was used to convey official recognition of the fact that the means to health go far beyond the remit of a national health service; individual pacts were to be made with: citizens, health sector operators and providers, other policy sectors, public institutions, the voluntary sector, the mass media, and the international community, in particular the European Union.The aim here was to secure the effective commitment of all interested parties for improving health and lay out the responsibilities of each of these. The subtitle of the plan also aimed at emphasising the government’s declared intention to base the new agenda for health policy on the principle of social solidarity, involving all citizens and promoting a shared sense of ownership and mutual benefit, a commitment to the pursuit of health, and not just health care, for all on an equitable basis. The key elements of the health target strategy initiated in 1998 were reiterated in important health reform legislation in 1999 (Legislative decree 229). This law emphasised the concept of population health and its intersectoral character.* The Annual Report on the State of Health Care in the Country3 directly linked information on the state of health of the population to the health targets presented in the National Health Plan 1998–2000. A good deal of the remainder of this report consisted of a chapter entitled “The new frontiers of health promotion” in which the population health approach was spelled out in quantitative terms, giving data on the state of health of citizens and describing research linking behaviour/actions to health states and providing concrete examples of population health initiatives in different parts of the country. The report also considered the question of equity in health and provided data on the socioeconomic and geographical distribution of ill health. People working in the field were already familiar with this information but the report made it available to a wider public. * A parliamentary act is as a rule signed only by the minister for the area involved and, where there is significant new expenditure, by the Treasury. In this case, over and above that of the Minister of Health, the Act carried the signatures of the Prime Minister and the Ministers of the treasury, finance, labour and social security, industry, universities and scientific research, environment, social solidarity, regional affairs and civil service. 133

HEALTH TARGETS IN EUROPE

The 1999 report presents more recent data than those used in the National Health Plan 1998–2000. 1999 also saw the Ministry of Health collaborating with the European Centre for Environment and Health of the WHO to publish Health in Italy in the 21st Century.4 The first part dealt with ageing, disease, health determinants, and equity while the second part described the health target strategy originally laid out in the National Health Plan 1998–2000. A draft of the national health plan for 2001–2003, subtitled “From health care to health”, was approved by the Cabinet in February 2001 and, as required by law, was sent for comments to other ministries, the National Health Council, and the regions.5 The draft plan focused less than the previous one on HTs, addressing other questions as well (future trends in the health sector, training of staff, innovative action for blood, transplants, drugs, and the future of the National Health Service in a federal system of government). Nevertheless, approximately half of the document was dedicated to examining implementation of the National Health Plan 1998–2000 at the national and regional levels. The new plan listed the actions taken to promote the key areas and the individual targets, including guidelines and programmes for mental health, AIDS, pregnancy and infancy, oncology, and health education. It also described the HT strategies adopted by the individual regions and the extent to which these conformed with the national strategy, including the adoption by the regions of an intersectoral approach. The starting point of the new plan was declared to be the HT strategy contained in the previous plan and the targets set by the European Union (New Community Action Programmes in the Health Care Sector 2001–2006) and by the WHO.6 It also claimed to have taken account of the principles contained in the European Union Charter of Fundamental Rights approved in Nice in December 2000.The key areas for the new plan were: improvement of the environmental context; promotion of behaviour and lifestyles favourable to good health; prevention, diagnosis and treatment of the principal causes of pathologies; reduction of inequality; and improvement of protection of “vulnerable groups”. Like the previous plan, but often in much more detail, actions to achieve targets were specified. However, fewer targets were quantified. On the other hand, much more statistical and descriptive information was given on the different aspects of states of health addressed.* * The future of the National Health Plan 2001–2003 is uncertain. The statutory consultative process was still in course when general elections were held in Italy in May 2001 in which the coalition government which approved the draft plan was defeated. 134

ITALY

Italy was rather slow in adopting HTs but when it did, it did so quite energetically. Over a relatively brief period, the HTs have become better specified and more clearly related to overall health policy. We now turn to examine the general context in which HT policy has been developed.

A constrained system of governance** Perhaps the most significant feature of the Italian system of governance is that governmental power has been dispersed both horizontally and vertically. This reflects in part the constitutional arrangements adopted in 1946 when Italy became a republic. It is also in part a product of the electoral mechanisms introduced at the same time. Finally, it is the result of how the governance system has evolved over time. Low horizontal integration of governmental power † derives from the de jure and/or de facto separation of power between the executive, legislative, and judiciary branches. Parliament until 1993 was elected with a pure proportional voting system and the mechanism which replaced this still gives considerable weight to proportional representation. This has resulted in coalition governments which, as a rule, have had slim majorities, have been dependent on small parties and have generally been unable to exert their will on Parliament, not even on the members of parties making up the coalition. Parliament has, also for this reason, been disinclined to be subordinate to the executive branch and has been very open to pressure from interest groups. The government can have a majority in the Chamber of Deputies but not in the Senate or vice versa and both houses of Parliament have broadly the same powers in the legislative process. All this means that the executive is by no means sure of getting its bills through Parliament, at least not in the form originally submitted. The judiciary branch, by virtue of its constitutionally protected independent status, has had the power to exert an important influence on policy by requiring the government and/or Parliament to modify measures which it finds to be in conflict with the Constitution.

** “Governance” includes the act of governing, the institutions, instruments, and methods used for this and relations between governments and between governments and citizens (OECD, 1995). † Pierson7 (p. 32) describes horizontal integration of governmental power as “the extent to which power within the national government is concentrated or dispersed”. 135

HEALTH TARGETS IN EUROPE

Finally, power has not even been well integrated within the central executive branch. The Prime Minister, far from leading colleagues of the Cabinet, has frequently been hostage to the leaders of the parties composing the coalition. Moreover, the civil service supporting the executive has, with some important exceptions like the Treasury and Ministry of Finance, been characterised by excessively bureaucratic procedures and by a legalistic mentality reflecting both the importance of administrative law in Italy and the fact that the majority of civil servants have degrees in law. The end result of all this has been an executive branch enjoying less freedom in policy making and implementation than its counterparts in probably most other European countries. The Italian system of governance is also characterised by low vertical integration of power.* The Constitution provides for a devolved system of government. There are three tiers of subcentral government – the regions, the provinces, and the communes – and none of these levels can be eliminated without a constitutional amendment, a complicated procedure. Of especial interest for our purposes here is the regional level of government. Devolution to the 21 regions of powers and responsibilities specified in the Constitution is mandatory and the regions enjoy considerable independence in the exercise of these powers and responsibilities. The heads of government of the regions are directly elected, as are the assemblies, and the regions have legislative, administrative, and regulatory power in the areas of responsibility allocated to them by the Constitution. Conflict between central government and the regions over jurisdiction, which is not infrequent, is in the last resort resolved by the Constitutional Court. There is a political consensus that Italy should move to a federal system of government although there is considerable disagreement on the precise form that this should take. This then has been the background to health policy making in Italy since the second world war. The 1990s saw important structural changes occurring in the political system with the disappearance or reshaping of the major political parties, electoral reform and the introduction of a qualified majority voting system and the emergence of a bipolar party system. General elections in May 2001 led for the

* Pierson7 (p. 34) describes vertical integration of governmental power as “the degree to which power is concentrated nationally or devolved to more local government authorities”. 136

ITALY

first time since the late 1940s to the election of a coalition of parties with a significant parliamentary majority in both chambers. It is early to say but this could have the effect of increasing the horizontal integration of central government. On the other hand, measures already introduced to increase the power of the regions and other measures promised by the new government will further reduce the degree of vertical integration of government.

Health policy in Italy Under the Constitution and by law, responsibility for health care is shared by central government and the regions. In both political and financial terms it is the most important responsibility the latter hold. Health care has been an arena for major intergovernmental conflict. Where, as has often been the case, this conflict has been jurisdictional in character, the Constitutional court has frequently found in favour of the regions, essentially affirming their autonomy in the matters of the administration and organisation of healthcare services. This low vertical integration of governmental power has meant that, compared with European countries with a unitary system of government, central government in Italy has had less discretion vis à vis lower levels of government in the design and execution of health policy. In addition, relatively low horizontal integration of power in the government of the healthcare sector has meant, for example, that Parliament could be sympathetic to appeals from doctors and other healthcare professionals and from national health service staff against central government measures adversely affecting their respective interests. For years it withheld its approval from the drafts of national health plans prepared by the Ministry of Health and in which central government policies for the medium to long term were described. This meant that the regions de facto enjoyed even greater discretionary power than they formally possessed. The judiciary branch has played an important role in interpreting national and regional jurisdiction in the area of health care. Another factor to bear in mind here is the overriding concern of the central executive with expenditure containment. In 1978, Italy replaced a Bismarckian style health system with a national health service.The Servizio Sanitario Nazionale (SSN) differs radically from the British NHS because of its highly devolved character, but is similar because until recently, it has been financed with central transfers (funded with compulsory contributions from employees, 137

HEALTH TARGETS IN EUROPE

employers, and self-employed and with general taxation). This has been a basic inconsistency of the SSN. The centre has had almost complete responsibility for financing public health care, but has had limited capacity to control how those funds have been used. The result has been chronic intergovernmental conflict and grave problems of accountability. The history of the SSN for most of the 1980s and early 1990s was a constant struggle by the centre to keep spending within the ceilings it set. Health policy was driven by macroeconomic policy and the Ministry of Health was at times seen by the regions as a mere adjunct to the Treasury.The state accused the regions of overspending relative to their initial allocations; the regions alleged that the state was deliberately underfunding health care. Each had some reason for taking its particular stance: there was well documented evidence of inefficient use of resources at the local level, while the Treasury officially admitted that it had knowingly allocated fewer financial resources to the SSN than were necessary. Seen from another angle, while the regions and the local health authorities had considerable power over the use of resources at the micro level, the centre was responsible for negotiating SSN staff national contracts, GP contracts, pharmaceutical prices, and fees paid to private providers, with important implications for expenditure obligations at the local level. The Ministry of Health tried to exert direct and quite detailed control over how resources were used by the local health authorities, but was resisted in this on jurisdictional grounds by the regions which were frequently supported by the courts.The centre felt obliged to fall back on macro tools which it had the legal power to use, such as imposing across-the-board freezes on the hiring of new staff, freezes on capital investment, exploitation of its monopsonistic power in its dealings with external suppliers of goods and services and, of course, underfunding. These were relatively effective in containing aggregate expenditure but had negative effects on efficiency and quality and on intergovernmental relations. This concern by the centre to enforce expenditure ceilings – despite the acknowledged fact that these were frequently unrealistically low – is explained by the fact that Italy from around the mid 1980s faced spiralling central government budget deficits and public indebtedness which by the early 1990s had reached crisis proportions. Hence, central government felt obliged to contain public expenditure on health (one of the largest items) despite the fact that, if we exclude the very late 138

ITALY

1980s and very early 1990s, public spending on health care since 1978 had risen in real terms no faster than in other OECD countries and, expressed as a percentage of GDP, was lower than quite a number of those countries. Italy was spending on health broadly what was to be expected given her per capita income level. Such a situation, particularly when combined with frequent changes in the government in power and/or minister of health in office, led inevitably to “short-termism” in healthcare policy. It is probably not exaggerated to imagine that the time frame adopted for policy making tended to be the statutory date for the submission of the next annual Finance Act or even the publication of the next quarterly public accounts by the Treasury. Repeated attempts were made during the 1980s to introduce managerial reforms at the local health authority level and to make the regions more accountable for overspending by local health authorities in their territories. However, these were mostly blocked or emptied of content during the parliamentary process. Moreover, the position taken by the Constitutional Court was that the regions could not be compelled to finance expenditure overruns in the absence of clear indications from the central government regarding the type and levels of services the regional health services were obliged to guarantee. The combination in the early 1990s of a serious crisis in the legitimacy of the political parties (due to the uncovering of widespread and systematic illegality in how they were financed) and spiralling budget deficits and public debt led to the appointment of two technical governments in a row* with a broad mandate to put the public finances in order. Over and above introducing emergency budgets imposing enormous additional taxes, the technical governments made the health sector, along with the pensions system and local government, a prime target for expenditure containment. Actually, health expenditure was mainly contained by shifting part of costs to patients with the introduction of steep copayments on drugs, specialist visits, and diagnostic tests; public expenditure on health care fell in absolute and real terms between 1992 and 1995. The problem of inefficiency was tackled by introducing general management in the local health authorities and major hospitals and by creating a form of health care quasi-market. * Under the Italian Constitution, government ministers need not be MPs.The technical governments were composed of prominent non-partisan figures headed by a person nominated by the President of the Republic and given a vote of confidence by Parliament. 139

HEALTH TARGETS IN EUROPE

Low vertical integration of government in the healthcare sector was explicitly acknowledged to exist, instead of being implicitly denied as in the past, and this was consolidated with virtually all administrative and organisational responsibility, which still remained with the state, being transferred to the regions in the hope of reducing jurisdictional conflict. The state retains powers for protecting the public/national interest in health care, for setting national policy goals and for coordinating regional health policies. Beginning in 1992, ownership of sources of revenue available to finance a growing portion of health spending has been gradually transferred to the regions with the aim of making them more accountable for how they used resources. The state guarantees funding for “necessary and uniform levels of care”; the regions can spend more than that but have to find the money themselves. The Constitutional Court found this arrangement to be legitimate.The SSN seems to be evolving into a form of federation of regional health services. Regional health services had always been quite different from one another, especially in terms of how they were organised and administered and also in terms of services available. This was demonstrated, for example, when the central government tried to introduce health care quasi-markets. The national government had to limit itself to laying down a reference framework containing certain key features to be adopted by all regions. It was left to the regions to decide on the precise model of managed competition to adopt. This meant that 21 different models of health care quasi-markets emerged over the 1990s (regarding, for example, the degree of separation between purchaser and provider).8,9 Regional autonomy means that now to a much greater degree than in the past central government has to “sell” its policies to the regions and to resign itself to possibly significant variability in the way its policies are implemented at the regional level.

An exceptional policy* The HT strategy was exceptional for its character, for how it was designed and for the manner in which it was implemented. As regards its character, the HT strategy stands out from most other health policies in Italy for the medium to long-term time frame it set itself and for the fact that there has been continuity. Moreover, the HT strategy has not been conceived as yet another tool * This section and that which follows draw on information obtained from interviews with participants of the members of the Cortona meeting. 140

ITALY

for expenditure containment; indeed, it could increase expenditure on health. Finally, Italy, which is normally somewhat of a laggard on the international health policy scene as far as innovation goes, has been quite swift in adopting HTs: the time lag between Italy and the very early starters was around six years and much less with respect to other countries. The origins of the strategy are interesting. The Minister of Health responsible for it, Rosy Bindi, took office in 1996 and left in 2000 – striking longevity for a minister of health by Italian standards and for that matter by those of other countries. This meant that she had time to grow in the office and to develop her own health policy. This included: a frontal attack on the power of the doctors’ organisations and on the pharmaceutical companies; revision of the strategy for managed competition in the SSN with more emphasis being given to “managed cooperation”* between the various actors in the health sector; and the development of the HT strategy. Bindi faced a deadline: by law the next national health plan was due by the end of 1997. The first draft she received of the plan in mid 1997 was almost exclusively process oriented and consisted of a series of actions to be taken in connection with the 1992 pro-competition reforms. Unhappy with this approach, the Minister arranged a weekend retreat in Cortona in Tuscany in the early autumn. Around 10 people were invited, including: a health economist who shortly afterwards would become Director General of the Planning Directorate of the Ministry; an epidemiologist from the government of the Emilia-Romagna region who would later become the head of the Agency for Regional Health Services, a consultative technical body for the Ministry and the regions; an epidemiologist holding a senior post at the Higher Institute for Health, another technical arm of the Ministry; a professor of sociology from the University of Padua; political advisors of the Minister; and the Minister herself. Two days of brainstorming produced the embryo of an HT strategy, even though this does not seem to have been the original intention.The Minister declared at the outset that she wanted an innovative plan which “spoke to the people”, one which citizens could understand and identify with.The discussion started from the determinants of health/ill health. Out of this came the idea for a “pact” for health involving a

* This distinction between managed competition and managed cooperation is made in Light 1997.10 141

HEALTH TARGETS IN EUROPE

series of actors. Only then did HTs enter the stage as a way of specifying what such a pact should concretely seek to do. The Cortona meeting concluded with agreement having been reached on a draft contents page for the plan and a subtitle, A solidarity pact for health. While it was not planned that HTs would play a central role in the plan, that this is what happened was perhaps not surprising given that a number of those at the Cortona meeting, the epidemiologists in particular, were very familiar with what was going on at the international level in the area. In drafting the plan considerable use was made of WHO, UK, and US publications on HTs but perhaps the most influential source were the papers on the determinants of health prepared for the Canadian National Forum on Health.11–13 Apparently the introduction to the plan written in the final drafting took direct inspiration from the UK government’s The New NHS published in December 1997.14 The support of other ministries and the regions for the plan’s implementation was clearly necessary and these were consulted during the drafting phase. The new draft of the plan was prepared in record time – at least compared with previous plans: six months from Cortona to publication. The HT strategy was exceptional also for the way in which it was implemented. It was launched at a jamboree conference, with the Prime Minister and an Italian Nobel prize winner for medicine present. Its format was eye catching, something uncommon for normally staid official publications. Massive media coverage was organised. After publication of the plan, the Ministry began working intensively on its execution. Six sets of guidelines on how to implement the HTs were prepared and eight special programmes were set up for mental health, AIDS, health in prisons, pregnancy and infancy, the aged, nutrition, immigrants’ health, and substance addiction. National plans for blood and plasma and for vaccines were published and an existing national programme for cancer was revised. Initiatives were launched for reducing road, work and domestic accidents, and smoking. A major financial investment was made, in collaboration with the regions and the National Statistical Office, in improving the health database. Preparation of the National Health Plan 1998–2000 had been dogged by problems of inadequate statistics; without data on health states and health risks, many targets could not be satisfactorily quantified. Moreover, many data that did exist were available only at the national level or for large geographical areas. This investment gave a fast payback with the publication in the autumn of 2001 of the report of a survey (with a sample of 60 000 142

ITALY

households) on citizens’ perceptions of health, on chronic illnesses, on handicap, on use of screening and diagnostic services and on risk factors, all broken down by age and sex and, most important, by region.15 The Ministry financed pilot projects in the regions relating to national HTs with ringfenced funds (a new law required that 3% of total SSN funding be dedicated to research and development). By early 2001, 10 regions had prepared HT strategies modelled entirely or in part on the national strategy. As already noted, the Minister of Health (a prominent oncologist) who succeeded Bindi prepared a draft of a new national health plan in which HTs again figured prominently. This benefited from improvements in the health database made since 1998 and had a greater quantitative content.

But also more of the same While having some “exceptional” features, not surprisingly the HT strategy in some important respects reflects, and is influenced by, the general health policy culture. A case in point is the design of the strategy. During the drafting of the plan for 1998–2000, a shift took place away from determinants of illness as the main basis of reference for the HT strategy toward categories of illness and so-called key areas of concern. The pressure for this came principally from within the Ministry of Health itself. The individual directorates sought visibility and campaigned so that their sectors would also be given a place in the sun. For example, the Directorate for Prevention successfully pleaded the case for including the environment as a strategic area broken down into subsectors – water, air, radiation, food, garbage disposal, etc. All this made the National Health Plan 1998–2000 more similar to previous plans than the Cortona meeting had intended. Less forceful but nonetheless influential were the health professions and patient associations in seeking mention in the plan. No one questioned the validity of HTs per se but all wanted a piece of the action, a slot in the plan when actions to achieve HTs were set out. The Minister or her office acted as a conduit for many of these requests. Interesting in this regard is the fact that the key area “Protect vulnerable groups”, which is not included explicitly in any other country’s HT strategy, was inserted at the particular request of Bindi, a devout Catholic from a small Catholic political party. Another factor reflecting the general policy environment was the low horizontal integration of the central executive for what regarded 143

HEALTH TARGETS IN EUROPE

HT policy.The Ministry of Health had consulted with a series of other ministries during the drafting of the plan to underscore the intersectoral character of the population health approach being adopted. An indicator of the real commitment of these ministries to the initiative was that no ministers other than the Prime Minister and Bindi herself attended the launching ceremony of the National Health Plan 1998–2000 and later attempts to set up an office to coordinate implementation of the plan failed. Rosy Bindi’s successor seemed, however, to have somewhat more success here and obtained a declared commitment from the ministers of education and agriculture to be involved in implementing the National Health Plan 2001–2003. Finally there is the regional dimension. The regions were consulted in the preparation of the plan but are reported to have given little substantive input. However, one proposal they did make – to create a unit to monitor implementation of the plan at the regional level – was not adopted. Ten regions have prepared HT strategies but, seen in terms of the half empty glass, 11 regions have not done so. The HT pilot project programme cited earlier was not a great success: 143 projects were presented by the regions but only 22 were considered to conform with the national HTs.2 An important factor here could have been that the regions may have different time horizons from the central executive (shorter or out of phase) as well as different priorities. For these reasons, the regions may be more inclined to support “traditional” healthcare activities as opposed to those which aim at promoting health. Having been only marginally involved in the development of the HTs, the regions may not have seen themselves as owners of, or stakeholders in, the HT strategy. After one year of the pilot project programme, the Ministry of Health stopped breathing down the necks of the regions, no more funding was made available and the programme died a natural death. In effect, the Ministry failed first to “sell” its strategy and then adequately sustain it. The fact that the Ministry relaxed pressure on the regions must have reflected a decline in interest of the Minister in the HT strategy, but this could have perhaps been because she was not receiving positive feedback on the political returns from the strategy. In any case, her attention was now focused on a major rethinking of the 1992 reforms, in particular those involving the creation of health care quasi-markets. She now had other priorities. The National Health Plan 1998–2000 was accused of being a book of dreams. In the same vein, the plan was criticised for lacking operational policies for attaining the targets. It was also faulted for not 144

ITALY

having reached those targets which had been quantified. To a considerable degree such criticism seems misdirected and suggests a somewhat ingenuous understanding about what an HT strategy is about and what it can realistically be expected to achieve. Judged in terms of the criteria established by the WHO for use when setting targets (for example, measurability and quantification), quite a few of the targets included in the National Health Plan 1998–2000 did not pass muster. Emphasising these defects may, however, be to miss the main point of the HT exercise. At least the National Health Plan 1998–2000 should perhaps be seen as primarily an attempt to educate the central and regional health policy establishments, other government agencies, non-governmental bodies, and citizens about the population health approach. This raises in turn the question of whether the national health plan is the most appropriate instrument for this. The national health plan was invented in 1978 and seen as a key tool, and perhaps the key tool, for governing the SSN. It failed to live up to expectations and over time little more than lip service came to be paid to central health planning. Probably the term “plan” is a misnomer and the document may more usefully be seen as a consultative paper providing a general description of central health policies. The scant legitimacy enjoyed by the plan as a policy instrument derives from the fact that in Italy the central moment in the policy making process is considered to be when the law which gives executive status to the policy in question is approved. This is in contrast with some other countries, perhaps most notably the UK, where the document describing a policy (a White or Green Paper) is given far more importance and attention than the laws enacting those parts of the policy which require parliamentary approval. It is interesting in this regard that the drafters of the National Health Plan 1998–2000 considered publishing it with a green cover to emphasise that what was being proposed was a strategy, a policy, and not a set of programmes.

Conclusion It is a truism that health policy in general and HT in particular are conditioned by the overall context of governance in which they are designed and implemented. What is more interesting is that in Italy HT policy has represented in some important ways a departure from policy making as it is usually practised. Why has there been this “exceptionalism”? Has it been due to a combination of factors 145

HEALTH TARGETS IN EUROPE

favourable to the adoption of an HT policy? Were proponents of HTs presented with a window of opportunity for an exercise in international health policy transfer? Or has there been a kind of paradigmatic shift in favour of the population health approach? An affirmative reply to the last query may be possible if the Minister of Health in the new government elected in May 2001 gives concrete support to the HT strategies developed by his two predecessors. A question mark hanging over the future of HTs in Italy is the accelerating pace of devolution of power, including in the health sector, to the regions. This will require greater capacity on the part of the central government to convince the individual regions to adopt HT policies and to ensure that interregional diversity in this respect remains within acceptable limits. However, past experience suggests that considerable heterogeneity will be inevitable and it follows that if we want to study HT policy in Italy, it will be necessary to go down to the level of the original region, rather as in the case of Germany, for example, or of other federations. The central government in Italy will probably be active in promoting HTs in the future, provided of course that it is anxious to promote national standards in health care. The population health approach de-emphasises processes and highlights results. National health standards, perhaps particularly in a country with devolved government, may be increasingly defined in terms of states of health of the population and its subcategories. The role of the central government would be to specify (in collaboration with the regions) standard states of health and then monitor attainment of these by the regions. The regions would send “report cards” on their healthcare systems to the central government, rather like what is envisaged under the agreement reached between the federal government and the provinces in Canada in 2000.16 In both countries the hope would presumably be that over time the report cards would contain increasing amounts of information on health states in place of data on how these states have been obtained. In such a scenario, and given the financial and political importance of health as a sector, HTs would become an important tool for governing the new federal system which is gradually emerging in Italy. References 1 Ministero della Sanità. Il piano sanitario nazionale 1998–2000: un patto di solidarietà per la salute (National health plan 1998–2000: a solidarity pact for health). Rome: Ministero della Sanità, Dipartimento della Programmazione, 1998. 146

ITALY

2 France G, Taroni F. Starting down the road to targets in health: the case of Italy. Eur J Public Health 2000;10(4 suppl):25–9. 3 Ministero della Sanità. Relazione sulla situazione sanitaria del Paese 1999 (Report on the state of health care in the country 1999). Rome: Ministero della Sanità, Servizo Studi e Documentazione, 1999. 4 Ministero della Sanità, WHO European Centre for Environment and Health. Health in Italy in the 21st Century. Rome: Ministero della Sanità, 1999. 5 Ministero della Sanità. Il piano sanitario nazionale 2001–2003: dalla sanità alla salute (National health plan 2001–2003: from health care to health). Rome: Ministero della Sanità, 2001. 6 WHO. Health 21: an introduction to the Health for All policy framework for the WHO European region. Copenhagen: WHO, 1998. 7 Pierson P. Dismantling the Welfare State? Reagan,Thatcher and the politics of retrenchment. Cambridge: Cambridge University Press, 1994. 8 France G. Healthcare quasi-markets in a decentralised system of government. In: Bartlett W, Roberts JA, Le Grand J, eds. A Revolution in Social Policy: quasi-market reforms in the 1990s. Bristol: Policy Press, 1998:155–73. 9 France G, ed. Politiche sanitarie in un sistema di governo decentrato: il caso della concorrenza nel Ssn (Health policy in a decentralised system of government: the case of competition in the National health service). Milan: Giuffrè, 1999. 10 Light DW. From managed competition to managed cooperation: theory and lessons from the British experience. Milbank Quart, 1997;75:343–64. 11 National Forum for Health. Children and youth. Sainte-Foy Québec: Editions Multimondes, 1998. 12 National Forum for Health. Adults and seniors, Sainte-Foy, Québec: Editions Multimondes, 1998. 13 National Forum for Health. Settings and issues. Sainte-Foy, Québec: Editions Multimondes, 1998. 14 Department of Health. The new NHS: modern, dependable. London: Stationery Office, 1997. 15 Istituto Nazionale di Statistica. Indagine sulle condizioni di salute e ricorsi ai servizi sanitari 1999–2000. Le condizioni di salute della popolazione italiana (Inquiry into health conditions and use of healthcare services 1999–2000. Health conditions of the Italian population). Rome: Istituto Nazionale di Statistica, 2001. 16 McCarthy S, Mackie R. Health deal points to election. Globe and Mail 12 September 2000:A1, A4.

147

11: England DAVID J HUNTER

Introduction A preoccupation with targets of all kinds has become a significant feature of public policy across the UK. There is not a policy sphere that has escaped the phenomenon. Whatever the domain – be it health, education or local government – each has been subjected to a blizzard of targets and a battery of performance indicators to monitor the implementation of the targets. The history of health targeting is of fairly recent origin. Indeed, until the early 1990s, there was no serious attempt to assess health improvement through a targeted approach. The change in policy was triggered by the then Conservative government’s support for an internal market in health care whereby there was to be a separation between those purchasing services and those providing them. Such a distinction made the transactions in health care more transparent and explicit and based on a system of contracts in place of a system of loose informal, and largely implicit, agreements. There was a need to be clear about the type and volume of health care to be purchased for a given outlay. But purchasing, or commissioning as it subsequently became known, was intended to be more than simply an endorsement of the status quo or a case of “more of the same”. The function was intended to challenge existing patterns of service delivery and to adopt innovative and creative ways of tackling health problems. In the early days of the NHS internal market the purchasing/ commissioning role of health authorities remained undeveloped and largely ignored. The emphasis was on the supply side and on establishing the hospital trusts to which the managerial talent gravitated. But within a year or so questions were being asked about the purpose of health authorities and the need for them to adopt a strategic perspective in regard to the health needs of their populations. So was born the first ever health strategy for England, although one had already been devised for Wales. The health strategy for England, grandly titled The Health of the Nation, was published in 1992 and 148

ENGLAND

survived until 1997 when the incoming Labour government decided to replace it with another, and in some ways more ambitious, strategy with counterparts elsewhere in the UK. Each of the health strategies has adopted a target based approach, an understanding of which is critical in any assessment of their outcome or impact. The remainder of this chapter is in three sections. The first section reviews the policy on targets both in the initial English health strategy and in its successor, Saving Lives: our healthier nation. Reference is also made to the NHS Plan which provides the framework for health policy and commits the government to producing and implementing national health inequalities targets. Two targets were subsequently announced in early 2001. There then follows a critical appraisal of the approach to health targets, largely based on a government commissioned evaluation of the impact of the Health of the Nation (HOTN) for which the author was a principal investigator. Many of the findings are applicable to the strategy and targets that have replaced HOTN although, as was intended by ministers, some of the lessons from that experience have been taken on board by the government. Of particular significance is that “adoption of targets is not the same as implementation of effective policies to achieve them”.1 Therefore, a concern with the implementation of targets is as important as their construction. The third, and final, section assesses the place of health targets in the context of the government’s overall health policy and speculates on the likelihood of success given criticism of the government’s policy making style and its particular brand of managerialism which may prove counterproductive, for reasons considered here. The discussion of health targets is restricted to England although the principal issues have a resonance throughout the UK. Nevertheless, potentially significant divergence in health policy between the four nations making up the UK is anticipated in the aftermath of political devolution.2,3 The UK is in the throes of major political change as a result of devolved assemblies in Wales and Northern Ireland and a devolved Scottish Parliament. Although there is a long tradition of administrative devolution in each of these countries it is only in the recent past that political devolution has become a reality. Hitherto, in respect of health policy at least, there is not a great deal of difference between the four parts of the UK. But this intra-UK convergence may not survive for long. Already there are indications of different approaches being adopted even if some of these appear rather inconsequential. Taken together, they may entail 149

HEALTH TARGETS IN EUROPE

significant departures from the English model or policy template which, under administrative devolution, has set the pace for the rest of the UK. In the area of health targets, it is evident from the health plans produced for Scotland and Wales that the fixation on targets in England is not paralleled by practice in these two countries. In comparison to the English Plan, the Scottish one is relatively light on targets.They exist but are more often couched in the language of broad ambitions rather than strongly fixed targets.4 It also appears that the emphasis on health, as distinct from health care, is greater in Wales and Scotland than England. Despite devolution, the UK remains the most centralised state in Europe and one of the most centralised in the world. A repercussion of political devolution has been a demand in at least some parts of England for elected regional assemblies. London already has an elected mayor and assembly. Among its responsibilities is an oversight function in respect of public health although it has no direct responsibility for health care. The government is divided on the merits of regional government in England but those ministers in favour are growing in number and influence. A policy statement on regional government is promised and there is talk of two experiments in different parts of the country to test public opinion. The day is probably not far off when the UK joins the ranks of other European countries in having a powerful subnational layer of government. But for now much of the political epicentre continues to revolve around the Westminster/Whitehall axis – certainly this applies to England and, following devolution, to a lesser degree throughout the rest of the UK. The other contextual factor of importance is that responsibility for health, as distinct from health care, lies with the Department of Health/NHS Executive and its ministerial head, the Secretary of State for Health. Notwithstanding the Secretary of State’s and department’s title, the reality is that the NHS and healthcare agenda dominates policy making and resource allocation formulae. The wider, and long-term, upstream commitment to the public’s health takes second place to the more immediate downstream concerns of the NHS – a classic case of the urgent forever driving out the important. Furthermore, where health targets have been devised they have been criticised for their medical bias rather than broad public health orientation and for giving the lead role in regard to their implementation to the NHS. The concern here is that the NHS, however well meaning, will always give priority to the needs of the acute hospital sector and will, if necessary, raid other budgets to terminate or reduce financial deficits in that sector. 150

ENGLAND

Review of the policy on health targets The English experience in setting health targets extends over the past decade or so as an integral part of formulating an overall health strategy.5 HOTN, launched in 1992, amounted to the first attempt by a British government at developing a strategy for explicitly improving the health of the population of England. Based on the WHO’s Health for All strategy, its overall aim was “to add life to years and add years to life”. The strategy focused on five key areas: coronary heart disease and stroke, cancers, mental health, sexual health, and the prevention of accidents. These were chosen for the following reasons: they are major causes of premature death or avoidable ill health; effective interventions were thought possible; and it was possible to set objectives and targets in the areas and monitor progress towards them. Twenty-seven targets were set across these key areas. Examples of targets are shown in Box 11.1.6

Box 11.1 Examples of Health of the Nation targets ●

●

● ●

●

To reduce the rates of CHD and stroke in under-65s by at least 40% by 2000. To reduce the death rate for lung cancer by at least 30% in men and 15% in women by 2010. To reduce the overall suicide rate by at least 15% by 2000. To reduce the rate of conception amongst under-16s by at least 50% by 2000. To reduce the death rate from accidents for under-15s by at least 33% by 2005.

The HOTN strategy demonstrated awareness that responsibility for the public’s health went beyond the NHS and involved other agencies, both nationally and locally. Nevertheless, the key coordination and implementation functions were accorded to health authorities. As a result, non-NHS interests regarded HOTN as primarily a health department/health service strategy. Its ownership by others was at best tenuous and half-hearted. HOTN was launched amidst widespread concern that health authorities’ purchasing function lacked any strategic framework or purpose. It was therefore widely welcomed and was seen to mark a significant turning point in shifting the emphasis in health policy from health care to health. However, the strategy encountered a major 151

HEALTH TARGETS IN EUROPE

obstacle in the government’s own ideological stance which refused to countenance the existence of health inequalities whose causes lay in various socioeconomic factors. This ought not to have been so surprising given that the government made no secret of its neo-liberal political aspirations. Indeed, the very words “health inequalities” were inadmissible in discussions between civil servants and ministers. “Health variations” was regarded as a more acceptable term. Rather more surprising was the sanctioning of a health strategy at all by a government generally opposed to central planning of any description, believing instead that devolved market-style solutions driven by consumer preferences were all that truly mattered in the provision of efficient services. The very existence of HOTN with its plethora of targets appeared to contradict the government’s own guiding philosophy and sat uneasily alongside its political beliefs. In addition to being criticised for not taking into account the socioeconomic determinants of health, HOTN and its targets were criticised for following a mainly disease based model. Again, perhaps this was not so surprising given that responsibility for drafting the strategy rested with those in the central department with a background in public health medicine and epidemiology. The specialty of public health medicine is not renowned for its adoption of a broader public health perspective in practice even if it acknowledges its importance in rhetorical terms. A further problem lay with the targets themselves and their construction, with claims from critics that some, like those for CHD and stroke, were set too low – rates were already decreasing in line with the targets set. The targets could hardly, therefore, be seen as challenging. This particular criticism touches on a critical problem with target setting generally. While targets should be challenging they should also be achievable and not so aspirational that they are of symbolic value only. A later section of the chapter returns to this issue. However important HOTN proved to be for the reasons cited above, its actual impact was less impressive. Progress towards the targets was decidedly mixed with three of the targets, for obesity, teenage pregnancies and smoking among young people, going in the opposite direction.7 The reasons for the failure of HOTN are multiple and complex and are explored in the next section. The arrival of a new government in May 1997 after 18 years in opposition heralded a new approach to health policy. In opposition, the Labour party had expressed a commitment to public health and to narrowing the widening health gap between rich and poor. On 152

ENGLAND

entering office it stood by its word and appointed the first ever Minister for Public Health who joined the health ministerial team at the Department of Health (DoH). Locating the minister in the DoH effectively rejected the views of those who suggested placing the post either in another central department concerned with broader health issues and the environment or at the heart of government in the Cabinet Office. Their objections to the DoH as a base lay in the conviction that the NHS would overshadow concern for public health issues. And so, according to the House of Commons Health Committee following their inquiry into the public health function, it has proved.8 A second action undertaken by the government was to commission a review of the impact of HOTN, something its predecessors had already committed themselves to do. Two university based research teams were commissioned for the task which had to be completed in about nine months in order that any lessons could inform the development of the new strategy the government was committed to producing. Although an earlier report by the National Audit Office had been critical of the progress towards meeting the HOTN targets, there had not been an assessment of the health strategy as a means by which central government could influence national and local policy. In short, the implementation issues were deemed to be important for a government committed to action and to ensuring that its policies made a difference on the ground.The main findings from the research studies are presented in the next section. The new health strategy appeared in consultative form while the evaluation of HOTN was still under way. It was titled Our Healthier Nation. The final strategy appeared nearly 18 months later by which time the title had been changed to Saving Lives: our healthier nation (OHN). It is tempting to read too much into titles but some commentators in this case regarded the change in title as implying a medical model of improving health with its emphasis on saving lives.9 The new strategy had two principal aims: ● ●

to increase the length of life and number of years free from illness to improve the health of the worst off in society at a faster rate than other groups and narrow the health gap.

It was the second aim which distinguished the new strategy from its predecessor. However, despite the government’s welcome commitment to tackling health inequalities and its open use of language that had 153

HEALTH TARGETS IN EUROPE

been banished from the political vocabulary by its Conservative predecessors, it refused to set a national target for reducing inequalities on the grounds that it was unnecessary. Instead, the government opted for local inequalities targets to be set by local agencies. It would then simply aggregate the local targets in order to assess the progress being made to reduce inequalities. Critics were not impressed or convinced by this argument and actively lobbied the government for a change in policy. The government conceded the point when it produced its NHS Plan in July 2000 (see below) and two national inequalities targets were announced in early 2001. OHN focuses on four key areas: CHD/stroke, cancer, mental health, and accidents. In contrast to HOTN, more challenging targets have been set in some areas, such as for suicide and undetermined injury. There is also a greater emphasis on health in later life, for example targets for reducing CHD/stroke and cancer now include those aged 65–74 years as well as those aged under 65 years. Learning the lesson from HOTN where there were arguably too many targets, the government opted for four in OHN in order to give the strategy more focus. But the strategy still has a disease based focus, as suggested by the first part of its title, Saving Lives, and the headline target of preventing 300 000 deaths. These, together with the proposal to introduce defibrillators in public places, seem to emphasise downstream health care rather than wider, upstream public health issues. As with HOTN, a disease based approach is unlikely to win support from agencies outside the health sector. This narrower focus on the public’s health is reinforced in the NHS Plan published in July 2000. The plan amounts to a 10 year strategy for modernising the NHS and the emphasis is unashamedly on healthcare issues, notably improved access to care services, increased number of hospital beds, and many new doctors and nurses. The wider health improvement issues receive brief attention in a short chapter buried in the body of the plan. In many ways the NHS Plan is a curious document, especially in terms of timing, since it was always unclear what it could usefully add to the policy stance already set out in several previous policy statements, including OHN. Indeed, many public health professionals expressed concern that the plan risks eclipsing the health strategy. One witness giving evidence to the House of Commons Health Committee’s inquiry into the public health function commented on the “muted consideration” of public health in the NHS Plan. 154

ENGLAND

The centrepiece of the NHS Plan’s short chapter on improving health and reducing inequality was mention of the creation of national health inequalities targets to narrow the health gap in childhood and throughout life between socioeconomic groups and between the most deprived areas and the rest of the country. These targets were published at the end of February 2001 and have been widely welcomed as demonstrating the government’s commitment to tackling health inequalities. Specifically, the two targets are to reduce by 2010 by at least 10%: ●

●

the gap in infant mortality between manual groups and the population as a whole the gap between the fifth of areas with the lowest life expectancy at birth and the population as a whole.

It has been claimed that the UK government is the first anywhere to produce such targets.10 Having produced the targets, the government is seeking assistance with devising a set of indicators, which would allow an assessment of progress towards the achievement of the targets to be made. Much of the government’s health policy in key areas is being driven through national service frameworks (NSFs). These are development plans, or blueprints, for particular services or client groups and represent national priorities which local health service organisations are expected to follow with appropriate adaptation to local circumstances. Building on earlier service frameworks for cancer services and paediatric intensive care, there are NSFs for coronary heart disease, mental health, and elderly people. One for diabetes is imminent. NSFs contain targets, including in the area of primary and secondary prevention, so they are focused on improving health and not exclusively on treating ill health. In its efforts to achieve change in the NHS and meet its targets, the government will be looking to NSFs as the principal vehicle to make progress. Although the NSFs have been generally welcomed by practitioners and managers as representing best practice in the respective areas they cover, there remain concerns about their implementation. They are ambitious and place additional demands on already hard pressed staff to reach the gold standard in a short space of time. Moreover, resources to achieve implementation may not be forthcoming and/or the necessary commitment to interprofessional working as well as crossagency working may be weak. In such a context the NSFs may face a struggle to survive. 155

HEALTH TARGETS IN EUROPE

Assessing the impact of health targets Probably the only significant national study of the impact of health targets in practice is the assessment of HOTN.11 As mentioned, and somewhat unusually, health ministers were keen to learn the lessons from the study in order that these might be incorporated in their own strategy to improve health. The lessons can be grouped under six key headings. Role of central government Central government has a key leadership role in ensuring that there is a consistent message across government in support of the health strategy and in fostering the development and dissemination of an evidence base for public health.The research found that those charged with implementing HOTN at local level needed to feel supported by central government in terms of national policies which were consistent with the strategy. Maintaining enthusiasm for the strategy at local level proved difficult where national policies were in conflict with it. In this respect, HOTN had not appeared to permeate national policy making in a way consistent with the intentions of its architects. Underlying philosophy A major criticism of HOTN, confirmed by the assessment, was that it failed to address the underlying social and structural determinants of health and health inequalities. The deficit acted as a barrier to implementation at local level because the strategy had less credibility, particularly among some local authority and voluntary sector partners who perhaps adopted more readily a broader definition of the public’s health than the healthcare system. Targets The research found widespread support for targets as a helpful way of prioritising and focusing efforts. However, there are a number of lessons to be drawn from the experience of HOTN. ●

● ●

156

National targets must be credible, i.e. based on sound and convincing evidence. The development of local targets needs to be encouraged. Process targets should supplement outcomes locally and nationally.

ENGLAND

In regard to the second bullet point above, OHN took this on board in respect of local inequalities targets to the exclusion of any national counterparts and got criticised for the absence of a national target. Ownership and communication Poor communication hampered HOTN in some quarters. The research found a lack of ownership of the strategy beyond the NHS, particularly among local authorities. Even within the NHS knowledge of HOTN was patchy and often absent altogether. Early enthusiasm for the strategy was not maintained with the result that it no longer registered with people and ultimately ceased to matter. Sustaining the strategy It was not until some time after its launch that HOTN became a formal part of the performance management system within the NHS. But by then it was too late because it was not regarded as important. Chief executives were not judged on their performance in implementing HOTN. For them, the “bottom line” issues were balancing the books and meeting waiting list targets. These could be “hanging offences” for senior managers, in striking contrast to a failure to meet HOTN targets. Encouraging partnership HOTN failed to engage with all the key partners required to make an effective assault on health inequalities and meet the targets set forth. For example, primary care practitioners were not centrally involved with the strategy or its implementation. As noted, some of these lessons the government sought to take on board in OHN. However, it will be some time before a realistic assessment is possible to establish whether or not the lessons have been fully absorbed in practice. As was pointed out in the previous section, the future of the strategy may be in doubt, having been superseded in the eyes of some observers by the NHS Plan with its narrower, and largely medically based, approach to health improvement.7

National inequalities targets It is far too soon to assess the impact of the national health inequalities targets but a number of issues need to be addressed at the outset. They illustrate more generally some of the problems and 157

HEALTH TARGETS IN EUROPE

potential perversities to which a target based approach can give rise, especially when coupled to a particular management style practised by government. For instance, unlike the targets set out in HOTN and its successor, OHN, the inequalities targets are not a simple extrapolation of trends. The gap between social classes for infant mortality rates and life expectancy is widening, according to the latest figures from the Office of National Statistics. Reversing the trend will require a degree of political commitment not hitherto witnessed. There is, however, a need to specify achievement of the targets by levelling up and not down, i.e. a measurable narrowing of the health gap should not be attributable to the healthier group deteriorating. The government claims it wants to hold the health status of the healthier group stable while improving that of the unhealthiest groups at a faster rate. Although the inequalities targets have been set for the NHS, they cannot be achieved solely by its own efforts.12,13 Intersectoral action across a range of agencies both nationally and locally is required.14 Yet it is not clear whether there will be any means of joint accountability put in place to ensure that all those agencies responsible for the implementation of the targets will be monitored accordingly. If only the NHS is to be performance managed against the targets then it is hard to see how it can be held accountable for the actions of those over whom it has no direct control. The temptation under such circumstances will be to focus on NHS interventions. Of course, these remain important but greater impact may be achieved through the reduction of poverty and social regeneration.These interventions are clearly more complex and multidimensional and do not reside neatly within the remit of a single agency. Perhaps the NHS can achieve more by using its influence to shape the policy agendas of other agencies. Certainly the House of Commons Health Committee is of the opinion that the NHS could do far more to regenerate areas of deprivation, exploiting its position as a major employer and purchaser of services.8 The adoption of a disease based set of targets carries dangers, however, if the support of non-health service agencies is sought. This is because different targets and success criteria might prevail in the case of a local authority than in the case of a health service agency. In a nice illustration of the point, Elson, a chief executive of a local authority, looks at chronic asthma in children and at how it could be reduced by intervention in their living conditions.15 From a healthcare perspective, success criteria were related to positive changes in peak lung capacity, reduced incidence of hospital admissions, and lower 158

ENGLAND

prescribing levels. But for the local authority the success criteria, had they been adopted, would have looked very different.They would have included the measured reduction in sickness absence from school, the improvements in literacy and numeracy in this group of children, and improvements in household income as carers were able to return to employment. In this example, none of the facts have changed. The same project can be presented in ways that hit the right targets in each agency.True partnership working needs to embrace both sets of success criteria in order to achieve mutual gain for both parties. Achieving the inequalities targets will require a range of broad brush interventions which will make it difficult to identify which interventions are making an impact and which are not.13 There will also be a need to avoid easy quick wins by targeting social and ethnic groups whose health problems are more easily tackled.Yet a government obsessed by an approach to performance management based on meeting targets could unwittingly unleash such perverse behaviour among managers anxious to be seen to be delivering on the government’s agenda. Other perversities are contained within the targets themselves, as Wilkinson and his colleagues point out. While few would dissent from a desire to reduce infant mortality, achieving such a reduction will not reduce morbidity and may actually serve to increase it in surviving premature babies.13 The target and interventions give no recognition to “high risk groups” for which certain of the interventions may be more or less pertinent, for example multiple births or extreme prematurity. There are other difficulties, too. For instance, local data are not yet available for the calculation of the targets at a local level. However, the numbers involved, particularly of infant deaths, will mean calculation of targets at small population levels will be difficult.13 One of the targets is area based while the other is based on socioeconomic group which will create challenges for implementation since the infant mortality target, though framed in social class terms, will require action to deliver it on an area basis. There are in addition more fundamental issues to consider in regard to the target industry in health, and indeed public, policy more generally. It is to these that we now turn.

Target based approach to health policy When governments adopt a target based approach to health policy they generally have two purposes in mind. These may be pursued 159

HEALTH TARGETS IN EUROPE

separately or jointly. First, they might want to ensure that policy is directed towards the achievement of health outcomes. Second, they might want to monitor progress in order to ensure that health policy objectives are being achieved. The distinction is a crucial one because it is sometimes unclear which function is seen as critical or whether both are viewed as equally important. In the case of HOTN, the government placed the emphasis firmly on the first purpose of a target based approach, i.e. that policy is directed towards the achievement of health outcomes. In contrast, in the case of OHN, the successor to HOTN, the government seems committed to both purposes. It wants policy to be focused on health outcomes but is also determined to ensure that these objectives are being achieved. The emphasis shifts again in respect of the NHS Plan where a more instrumental position is adopted, namely the achievement of health policy objectives. Evidence of the government’s resolve for ensuring that its policy objectives are achieved lies in its performance management framework and accompanying performance indicators. While the framework shifts the emphasis from inputs and processes to outputs and outcomes for the first time, concern remains about its top down bias and the degree to which it is being driven by central government in an inappropriate command and control fashion. Moreover, in addition to the framework itself there are various performance indicators in evidence (some 41 or so) with attendant concerns about the ability to deliver on so many of them.There are also some 200 performance service agreements published by the Treasury to be added to the list. Managers are required to respond to these. And there is more. The Department of Social Security has produced a further set of poverty indicators as an audit tool for monitoring progress in alleviating poverty and reducing health inequalities. As is apparent, a huge industry has grown up around targets. A target based approach to policy implementation is predicated on a rational model of policy making which many analysts acknowledge to be flawed and oversimplistic.16 In contrast, complexity science both accepts and seeks to understand complex adaptive systems and to adopt appropriate mechanisms to guide the implementation of policies. A target based approach is an imperfect process in an imperfect environment. It cannot be, as is often mistakenly assumed, a rational linear process. In practice, the construction and implementation of targets is a messy affair. Targets may have multiple purposes and meanings. For example, they may be seen as a source of aspiration 160

ENGLAND

rather than a management tool. They may achieve more as a symbol of policy than as precise instruments designed to implement policy to the letter. Under HOTN, targets were seen largely in symbolic terms. In contrast, under OHN the government’s strong managerial and technocratic bias may dominate. Evidence of application will be sought unless the effort involved in modernising the NHS overwhelms all other health policy considerations. As noted earlier, achieving targets involves striking a fine balance between being sufficiently challenging on the one hand and avoiding being wholly unrealistic on the other. Targets should, therefore, avoid easy successes, lack of ambition in target construction, oversimplification, and the proliferation of too many targets. Ideally, too, target setting should ensure that targets are linked to resource flows and are part of a performance management system with real managerial grip. But targets should also be “owned” by those charged with their implementation. They may otherwise lack meaning and relevance. As much of the foregoing discussion has suggested, health targets have both strengths and weaknesses which others have analysed.17 The strengths include targets being purposeful, achievable, realistic, owned by those they will most affect, and as far as possible evidence based. There are also technical issues to consider, including small numbers, availability of data, definitions, and the degree of precision and methodologies. Finally, there is the matter of attribution and the related matter of influencing factors over which there is no direct control. Health targets can possess, or give rise to, various undesirable features. These include: ●

●

●

●

●

perverse incentives – a disease oriented, target based approach may achieve quicker results but be less effective in reducing inequalities distortion of data, leading to goal displacement and manipulation of results target setting in the absence of power and resources to bring about change too many targets – priorities become meaningless if they include everything measurability – there is a risk that what gets measured gets done; targets could be focused on areas, such as acute medical services, where data are easily collected in contrast to areas, such as rehabilitation services, where data are patchy. 161

HEALTH TARGETS IN EUROPE

At various stages in the history of health targets in the UK all these aspects of targeting have been in evidence to a greater or lesser degree. Most recently, some of the drawbacks of a target based approach just noted have been especially visible as a consequence of the government’s managerial style and hard-line conception of performance management. There is criticism that targets have been used to micro-manage public services so that not only policy ends are subject to targets but also the means of achieving them. In such a top down, command and control climate, public service leaders have been denied the space to manage effectively. Instead, they have devoted time and energy to meeting centrally imposed targets. As the House of Commons Health Committee heard from witnesses in the course of its inquiry into the public health function, the emphasis in the NHS on top down targets has served to stifle innovation and creativity. This has, in turn, led to managers doing what was expected of them rather than what was most desirable locally. Arguably, the fixation with targets has resulted in considerable “gaming” in order to appear to be meeting the targets. It has also tilted the balance in favour of holding frontline practitioners to account at the expense of allowing them sufficient freedom and space to lead and devise local solutions for local problems. This analysis of the disadvantages of targeting is not confined to outside commentators. A report from the Cabinet Office’s Performance and Innovation Unit, at the heart of government, puts forward a strikingly similar critique.18 A new approach to the deployment and application of targets in complex adaptive systems, of which the NHS is an excellent example, is needed to overcome the rigidities and perversities arising from the present approach adopted by the government.To this end, complexity science may have important insights to offer.19,20 It views healthcare systems as complex adaptive systems. Unlike “new public management”21 thinking with its overbearing emphasis on targets and performance indicators, complexity science seeks to go with the grain of human behaviour and endeavours to make sense of how people and systems behave. Much of it is intuitive. It starts from the premise that health systems require greater tolerance for ambiguity, an appetite for novelty, and a capacity to act even when facing great uncertainty and scant evidence. In such a setting relationships, or networks, are key. There is a need to distribute control rather than to centralise it. To centralise means devising complex bureaucratic controls, often based on a battery of targets, and performance management systems which risk becoming self-defeating and diverting of attention away from the 162

ENGLAND

problems that they are ostensibly intended to help resolve. A challenge for policy makers is how to balance the need for targets to assess policy impact and, hopefully, success while not stultifying or diverting the very creativity and social entrepreneurship needed by managers and practitioners in order to tackle “wicked issues” for which there are no easy or simple solutions.

Conclusion A target based approach to health policy is an important feature of public policy in the UK as it has been for a decade or so. Successive governments have grappled with the inherent complexities arising from deepseated inequalities the causes of which are complex and multifactorial. But as the experience from the UK, or England to be precise, shows, a target based approach is not an easy or soft option. This finding parallels experience elsewhere.16 Targets possess many potential pitfalls which can confound the unwary. Setting targets is relatively easy but their implementation may be considerably more difficult, particularly if a naïve model of the policy process as rational and linear is adopted. Those responsible for setting targets need to give adequate attention to the implementation process and ensure that the requisite skills and resources are in place to allow the targets to stand a chance of success. Finally, the targets must be seen to matter. If not, they will prove shortlived and will cease to be credible or taken seriously.There is still a long way to go in the UK in terms of using targets effectively as an instrument of health policy. However, there is now a sufficient body of experience at hand with which to construct a more effective approach should a future government wish to do so.

References 1 McKee M, Berman P. Health targets in Europe: learning from experience. Eur J Public Health 2000;10(4 suppl):1. 2 Jervis P, Hazell R. Devolution and health. London: Nuffield Trust, 1998. 3 Jervis P, Plowden W, eds. Devolution and health. First annual report. London: Constitution Unit, University College London, 2000. 4 GPC Scotland. Devolution and health: Scotland. Quarterly report, December. London: Constitution Unit, University College London, 2000. 5 Fulop N, Hunter DJ. The experience of setting health targets in England. Eur J Public Health 2000;10(4 suppl):20–4. 163

HEALTH TARGETS IN EUROPE

6 Hunter DJ, Fulop N, Warner M. From ‘Health of the Nation’ to ‘Our Healthier Nation’: a case study from England. Policy Learning Curve Series No.2. Brussels: WHO European Centre for Health Policy, 2000. 7 National Audit Office. Health of the nation: a progress report. London: HMSO, 1996. 8 House of Commons Health Committee. Public health. Second report, Volume 1. Session 2000–01. London: Stationery Office, 2001. 9 Fulop N, Hunter DJ. Saving lives or sustaining the public’s health? BMJ 1999;319:139–40. 10 La Parra D, Alvarez-Dardet C. The new UK health inequalities targets. J Epidemiol Commun Health 2001;55(5):289. 11 Department of Health. The Health of the nation: a policy assessed. London: Stationery Office, 1998. 12 Appleby J. Health inequality targets. Health Service J 2001;111:340. 13 Wilkinson J, Bailey K, Grant S. A Review of the National Inequalities Targets. Occasional Paper No. 2. Stockton: Northern and Yorkshire Public Health Observatory, University of Durham, 2001. 14 van Herten LM, Reijneveld SA, Gunning-Schepers L. Rationalising chances of success in intersectoral health policy making. J Epidemiol Commun Health 2001;55(5):342–7. 15 Elson T. Public health and local government. In: Griffiths S, Hunter DJ, eds. Perspectives in public health. Oxford: Radcliffe Medical Press, 1999. 16 van Herten L. Health Targets: navigating health policy. The Hague: CIP Gegevens Koninklijke Bibliotheek, 2000. 17 Nutbeam D, Wise M. Planning for health for all: international experience in setting health goals and targets. Health Promotion Int 1996;11(3):219–26. 18 Cabinet Office Performance and innovation unit. Strengthening leadership in the public sector. London: PIU, 2001. 19 Axelrod R, Cohen MD. Harnessing complexity: organisational implications of a scientific frontier. New York: Free Press, 1999. 20 Foote C, Plesek P. Thinking out of the box. Health Service J 2001;111:32–3. 21 Hood C. A public management for all seasons? Public Administration 1991;69(1):3–19.

164

12: A European review MORTON WARNER

Introduction The spectrum along which the human endeavour of healthy living travels is bounded at one end by notions of faith, peace, harmony, and justice for all and at the other by the preclusions associated with evidence-based medicine. This is the territory within which health targeting must operate. Add to this the list of players – politicians, professionals, technocrats, managers, and the public, each with their many functional subdivisions and levels – and the permutations required for setting off in any particular direction can be legion. But in the period since the second world war, and particularly in the last 30 years of the 20th century, the “health” of both individuals and whole populations has been high on the agenda of most nations in western Europe. The case studies in the earlier chapters show the WHO to have been a key influence, especially following on from the postwar infrastructure building activities that took place in the 1945–70 period. Every few years a renewal process has occurred that built on Health for All (HFA)1 and different countries used the stimulus in their own way as it suited their own sociopolitical stage of development. Some, such as the UK, Germany, and Sweden, denied the right of the WHO to mandate good practice within their jurisdiction and others, like Lithuania and Hungary, aligned with HFA as a way of joining mainstream western thinking following years of domination by the Soviet Union. The EU, in the Maastricht and later Amsterdam Treaties,2,3 built upon the 1961 Council of Europe Convention on Human Rights4 and have focused on public health issues in an evermore broad way, mixing political and technical approaches. Health targets are now very much part of the discussions, but it remains to be seen how the WHO–EU relationship will develop. Who will carry the “health flame”, and how, is open to speculation but some clues can be gained from the case studies. Health targets could, at the least, be described as playing an interesting role in developments but it can be argued that their process of formulation – internationally, 165

HEALTH TARGETS IN EUROPE

nationally, and locally – always has and will continue to bring together individuals and organisations, political and professional, from across the spectrum. The concept of health targets is one which, in its own right, brings together strange bedfellows even though, like cats, they are often difficult to herd. There is much to be learned from what has gone on so far in the health targeting saga. What follows is an overview analysis drawing on the case studies given in the preceding chapters and on other examples to examine: ●

● ● ●

the variations and dichotomies in European political, social, and economic development which have had an influence on target development (a necessarily partial view) stakeholder perspectives the tactics employed to get a target on the books targets as a route to intersectoral cooperation and integration of services through the foundation of new partnerships.

Political, social and economic development: variations and dichotomies The period of reconciliation The second world war left nations throughout Europe in a state of disarray and many governments recognised that their returning fighting forces, as well as those who had suffered at home, were owed a debt of gratitude. Also, some of the social inequities and inequalities which had been present at the turn of the century were under challenge by the many who had seen a new social order emerge. It is within this context that welfare state idealism took off – a partial payment for the debts owed and a way of reconciling relationships between the governments who ordered men into battle and those who suffered the consequences. Beveridge,5 for example, captured the spirit of reconciliation in the UK and was widely drawn upon by other nations. Peace and harmony were part of the plan. It is instructive when looking at the widely quoted WHO definition of health to think of its origins which had first been proposed by Henry Sigerist in 1941: Health is not simply the absence of disease: it is something positive, a joyful attitude towards life, and a cheerful acceptance of the responsibilities that life puts upon the individual.6 166

A EUROPEAN REVIEW

What is missing in the WHO statement is the last phrase. This was no longer an era for calling for individual sacrifice in any form; enough was enough and justice was of paramount importance. It must be remembered also that in 1941 medicine could offer little in the way of cures: faith in the care largely provided by nurses was to provide the basis of hope. And a broader faith that government would nurture its people through state interventions was ever present. Service growth and cost controls The economic climate across western Europe was buoyant in the postwar period and the spirit of reconciliation lay alongside developments in science which changed the patterns of medical possibility. By the mid to late 1960s the range of medical and allied health professional groups had broadened considerably, hospitals had been erected on a grand scale throughout western Europe and Scandinavia, but a general economic recession was in the offing. The time had come for a look at cost control; and whilst “targets” as an expression had not yet come into general usage, the work of Peter Drucker7 found its home in the public sector – management by objectives came into favour. The pressure to control public spending has never gone away, but the context has changed. Throughout the 1990s, as the EU formed a more cohesive trading block competing with the other global economies both east and west, the pressure was on reducing taxes, wage demands, and the price of products, in that order. Paradoxically, for tax funded health care this has come at a time of massive scientific discovery and insatiable public demand for cures. Having come to accept “reconciliation” and what it represented as an integral part of the social fabric, citizens in all the case study countries treat harshly any government that threatens the basic right to health service provision. And in the Countries of Central and Eastern Europe (CCEE) group there has been a high turnover of power where free market approaches (often pushed for by the World Bank) have endangered universal access. The WHO arrives on the scene It was the 30th World Health Assembly that laid the foundation for Health for All in May 1977: The main social target of governments and the WHO in the coming decades should be the attainment by all citizens of the world by the year 2000 of a 167

HEALTH TARGETS IN EUROPE

level of health that will permit them to lead a socially and economically productive life (Resolution WHA 30.43).

“A blend of today’s reality and tomorrow’s dreams” was how Dr Jo Asval, WHO Regional Director for Europe, described the vision of the 32 member states of the European Region when they adopted the first set of targets in 1984. But, as illustrated in the country case studies, reactions to the actual targets both individually and as a collectivity varied. On the positive side many were influenced by the presence of the targets and involvement in their construction. Spain, at this time emerging from the Franco era, used them to shape and influence the Spanish General Health Law of 1986 and most of the autonomous communities have used them directly. Sweden, by contrast, whilst intimate to the development process, ignored them as being irrelevant at the national level (which is not responsible for health services) and had little response at the time from the county level, which was. The Bonn government committed itself but did little to implement the commitment.The UK and Italy were the same. Finland, however, was able to play a large part on the European stage and its influence was enormous: target applications were both monitored and evaluated. Two things emerge from this summary. ●

●

168

First, the WHO, operating at the time in the only way it knew how, and within its constitution, assumed that sign-up by national governments was sufficient. In several of the countries – Sweden, Germany, and Italy – this was clearly wrong given the autonomy of their subnational levels. This has been corrected in Health 218 which recognises that there are significant differences within countries that require attention and that action at the regional level can make a real contribution to the improvement of health. Indeed, Health 21 specifically calls for strong action at the regional level to implement its targets. Second, of necessity, the timetables of national, regional, and local governments depend on many things. Valencia and Catalonia in Spain, Ostergötland in Sweden, North Rhine-Westphalia in Germany, and Wales in the UK were, for example, all founding members of the WHO Regions for Health Network in 1991 and had embarked on HFA activities in the years before. Each in its own way had made political statements about autonomy.

A EUROPEAN REVIEW

Lithuania (as part of the Baltic Region at the time) also joined to emphasise its independence from the Soviet Union. Hungarian regions were similarly inclined in relation to their own country and their national Ministry of Health was also encouraging in this regard. The WHO’s technical contribution and its ultimate impact – although not always on its own timescale – should not be underestimated. In more recent times target setting concepts have expanded and now include both outcome and process targets, with the latter encouraging national, regional, and local development. This should help overcome earlier objections from countries such as Finland and it should reduce the WHO’s dichotomy with the EU and assist it in its new “cohesion” approach.

The EU role The EU has, since its inception, been primarily market oriented but has used this in social development areas, including public health, in a two pronged approach involving economic and political considerations. The World Bank, following the publication of its Development Report in 1993,9 has been similarly oriented in its health funding in the CCEE. This is now particularly important as the EU is confronted with the task of integrating the newly attending states. In addition, it has increasing requirements for a cohesive approach to health protection and to promote convergence between member states in the health and social fields through increasing cooperation, information transfer, and transparency. The Treaty of Amsterdam in 1999 expanded the competencies of the EU beyond those specified in the earlier Maastricht Treaty. Article 152 gives increasing importance to health promotion and health protection. However, it is the proposals for the Public Health Strategy and Action Programme (2001–6) that really provide the new and comprehensive focus: ●

● ● ●

improvement of health information and the development of a comprehensive public health system rapid reaction to health risks consideration of health determinants strengthening of health promotion and prevention 169

HEALTH TARGETS IN EUROPE ●

the establishment of a European Health Forum with an advisory function.

The EU, of course, is no stranger to the field of targeting in a whole range of areas other than health. But it appears in very recent times to have had to back off on “harmonisation” with its implications for targeted and timed points of convergence, and instead is looking for agreement that certain destinations are strategically important but that the journey taken will vary from country to country and at subnational levels. This approach, more acceptable to current member states, has been driven by the reality of the relatively poor socioeconomic situation in the new accession countries and others to come. The EU is also supportive of social development for member states within its Objective 1 funding. The power to persuade that health and economic development go hand in hand, particularly at the subnational level, has been important in many of the countries reported on in this book. So, over a period of nearly 50 years the dichotomies that from time to time have displayed themselves in sharp relief – attempting continued reconciliation in the face of cost pressures and recession, and attempting to follow parallel tracks of health development and economic regeneration through market mechanisms – are being cajoled into a common sense of purpose. In the social field, health targets have played an important role: whilst the WHO spearheaded the movement, the EU was no stranger to various European targets for cancer reduction and the like. The breakthrough for both has perhaps come with the recognition that no intergovernmental organisation can orchestrate local action, but that this level is critical, in aggregate form, to improving social cohesion in Europe. Health targets are increasingly likely to be developed, owned, and implemented at the subnational levels using the 2001–6 action programme as a lever.

Stakeholder perspectives As indicated at the outset, it is not only the political cadres that have an interest in health targeting: professionals, technocrats, managers, and the public all have their own particular concerns as well. They each cast their own scrutiny over the development process and have a fundamental stake in the anticipated outcome. 170

A EUROPEAN REVIEW

Suchman,10 as far back as 1967, recognised the mutually inclusive but differently motivated expectations that exist on the part of persons or groups involved in developing, operating, and evaluating new programmes. By 1976 Warner and colleagues11 had constructed a model that described a number of evaluative or perceptual pathways which represent a variety of stakeholder positions. The cuboid design is set out in Figure 12.1 and involves “data type”, the “time perspective” over which data are required, and the arrangements for “information collection”.

Ds Soft Data type Dh

Hard

Tl

Long

Ts

Is

Special

Ir

Time perspective

Short

Routine

Information collection Figure 12.1 The perceptual pathways of stakeholders in health development11

From this eight “perspectives” emerge, if the time elements – short and long term – are fixed as the variables around which the others rotate. The utility of taking this approach is that it begins to explain what has either been confronted head on in some countries (notably Finland and Sweden) or has simmered under the surface in others (for example UK and the Netherlands), that outcome targets by themselves may either be unhelpful or, if given dates for achievement, positively dangerous at the political level; and for the public, professionals and managers, unachievable without detailed consideration of financing and resource reutilisation. 171

HEALTH TARGETS IN EUROPE

Tables 12.1 and 12.2 identify the pathways and give brief descriptors of the perspectives associated with them. At the extremes, (i) and (viii) represent the ultimate dichotomy of perspectives. Table 12.1 Short-term perspectives of stakeholders in health development Pathway (i) IsTsDs

(ii) IrTsDs

(iii) IrTsDh

(iv) IsTsDh

Perspective of data type and information collection Crisis oriented approach completed on a retrospective basis and within very limited timeframes with a great sense of immediacy. Of use principally to politicians, public, and managers. Case studies and summary of critical incidents, subjective client and professional programme assessments, studies of crises. Of use to all stakeholders. Utilisation data, worker activity levels, quality of care, special problem identification. Of use to managers, central government managers, professional workers, and politicians. Best for identification of special target groups and short-term effectiveness measures. As for (iii), plus epidemiologists.

Table 12.2 Long-term perspectives of stakeholders in health development Pathway (v) IrT1Ds (vi) IsT1Ds

(vii) IsT1Dh

(viii) IrT1Dh

Perspective of data type and information collection This groups with (ii) and is the response to the demand by researchers that events be recorded at the time they happen. Mainly consisting of a piecing together of programmes in a case study, historical way. This demands that soft data be stored systematically at the time of occurrence. Of use to researchers and government policy makers in better understanding of freak data situations. Data collected on retrospective or prospective basis re: special target groups, or special problem areas. Can be used to develop needs/demands statements. Of use to managers, researchers, and consumer groups. Consistently collected data with previous definitions explicit; allows for a utiliser audit and a statement of health and social status indicator changes. Of principal use to researchers, particularly epidemiologists, and public policy analysts.

For the first, the political paradigm of short-termism dominates and for the second, this is the area of long-term interest to researchers, particularly epidemiologists and policy analysts. With the intervening pathways there is a mix of interest or stakeholder perspectives and different groups find value in each. 172

A EUROPEAN REVIEW

Van Herten and Gunning-Schepers have drawn attention elsewhere12 to the need to create an optimal balance in setting targets. Technocratic and participative approaches are to be set against each other on one axis and political policy makers and professionals are represented at the extremes on the other. But perhaps it is not possible to achieve an optimal balance, only a need to ensure all the perspectives are in the melting pot when the package of targets is complete. In their various formats all the case studies give emphasis, implicitly or explicitly, to what is emerging as a common set of criteria for the adoption of targets (Box 12.1).

Box 12.1 Criteria for adoption of targets ● ● ● ● ● ● ●

Credible Selective Quantifiable Timely Monitorable Balanced Ethical

Targets fundamentally have to be credible. If clinicians are going to say “I really can’t believe this is important” or “You can’t be serious in suggesting that”, then it really is a waste of time having such a target. You also have to be selective. You cannot have targets for everything. So, there is an issue of how to set priorities. In addition, there do have to be sufficient quantifiable targets which can be monitored and which are timely. In other words, a return on investment must be shown within two, three or five years, a period important to politicians who ultimately must have sanction and responsibility for setting targets. Balancing is the business of getting the range of targets right, from prevention through to rehabilitation. And, of course, achievement can only be undertaken by ethical means. The more important issue is, however, whether all stakeholders have had the possibility of involvement and of moving towards an optimal balance. The case studies provide some answers in terms of the degree of involvement and of the account taken of different perspectives. ●

At one extreme, Italy (the latest country to develop health targets) has been highly technocratic and political, operating at the 173

HEALTH TARGETS IN EUROPE

●

●

●

national level, but anticipates public participation and professional involvement will ensue during regional implementation. At the other, in the Swedish counties, where wide ranging political and public involvement has taken place, North Rhine-Westphalia, through its state conferences, and the Spanish autonomous communities with their health portals (e-health based), there have been attempts, not always wholly successful, to balance all the stakeholder inputs. All have a minimum of 10 years experience of the development process. Finland reports a picture of some vacillation. As an early entrant into health targeting its balance tended towards technocratic, outcome oriented approaches and these later caused political scepticism. Following this, the emphasis was on process items but of late both components are being brought into play. The same could also be said for England, but 10 years on from the Finland of the early 1990s. But the latest NHS national service frameworks are much closer to the optimum balance, though unduly technocratic in terms of performance management. Concern can also be expressed about the potential problem of calcification by targets and about the hand picking of those easiest to achieve.

All in all, then, in many jurisdictions health targeting has gone through a maturation process that often at its initiation was expected to take 10–15 years to achieve. The criteria for target selection are in common usage and the need to engage all stakeholder groups in ownership is generally accepted. Much, by the way of progress, is dependent on recent political history and the relative levels of power achieved by each of the stakeholders as developments unfolded.

Tactics and targets Goals and targets of health policy do not exactly choose themselves, although some items become seemingly more obvious as candidates. There are two levels of thinking.The first would say “if there is a lot of some disease around then it must be given priority attention”, so heart disease and cancer rank high. The second, and often less articulated, argument is about how to define the range of responses required for prevention, diagnosis, alleviation or care, and rehabilitation and what is the right balance between quantity and quality of life. And all the while the political elements involved in health targeting (as opposed to the technocratic and professional) – public concerns, resource 174

A EUROPEAN REVIEW

allocation and the like – hover in the background, often counterpoised by the emerging salience of evidence-based medicine. So, the discussion begins to centre on tactics, on how to have a target included on the “list”. Generic expressions like “children”, “heart disease”, “cancer”, “mental health”, and “old age” do not suffice, but what does? The answer lies in “specificity” and a sense of immediacy (the very short timeframe); and the consequences may be chronic reductionism, a disease in itself from which some countries (particularly Italy and Germany) seem to suffer more than others. In the previous section emphasis was given to the different stakeholders and here again they come into play, but with added attention to health professionals and the voluntary sector (known variously across Europe as non-governmental organisations or civic society), both of which contain narrow special interest groups. Figure 12.2 indicates the sort of mature picture that is emerging across those countries where health targeting has been under way for some time.

1

Subject Specific area

Political interest high

2

• Paediatric cardiology • Heart attack • Alzheimer's disease

• Children

• Prostate cancer • Acute schizophrenia

• Heart disease • Environmental planning

• Suicide

• Cancer

• Road accidents • Tobacco control

• Old age General

• Cystic fibrosis • Mental health

• Perthes' disease

4

Low

3

Figure 12.2 Optimising target subject identification

Typical goal areas are identified in Sectors 2 and 3 and target area examples with a relatively high chance of being included occur in 175

HEALTH TARGETS IN EUROPE

Sector 1. Tacticians choose key items for attention to increase the chance of attracting funding. Old age

Becomes, for example

Alzheimer’s disease Heart attack Prostate cancer

Cancer



Prostate cancer Tobacco control

Heart disease



Heart attack Tobacco control

Mental health



Acute schizophrenia Suicide

Environmental planning



Road accidents

Children



Paediatric cardiology

Of course, many more items are included in the target lists contained in the case studies. But what happens to the many which are not, those that fail to get the necessary technocratic and professional votes, that have too few people suffering from them to worry about – those, for example, with cystic fibrosis or Perthes’ disease in Sector 4, who may only receive scant attention? What happens to whole person/ family care? What about a comorbidity in an old person that is not included for targeting? This is a danger in the tactical game that is played. In countries where the general practitioner system is underdeveloped (much of the CCEE) or under threat (Sweden and the UK) or able to be bypassed (France and Germany), health targeting may do potential harm if health service targeting is not also employed. Rightly, then, primary health care per se is, for example, the subject of emphasis in German targeting and is being given support in the reforms in the CCEE.

Targets: the route to intersectoral action and service integration? Achievement of health targets is dependent upon close partnership working and integration within and across the health and social care sectors. This is a major challenge expressed in all the case studies and well beyond. The general question, long posed, is how to move from a vertical to horizontal approach. 176

A EUROPEAN REVIEW

Perhaps, though, this challenge can be turned around. How can targets be used to promote intersectoral action? Some early endeavours are concentrating on the creation of virtual organisations13–15 supported by network development.16,17 These can be associated with “integrated care pathways”18,19 and “clinical network”20 activities now under way in many countries in Europe, hoping to improve efficiency and effectiveness in service delivery, and with the funding provided by the EU to address partnership issues.

Target setting as a process for development It is particularly at the subnational and more local levels in Europe that some evidence exists of valuable dialogues taking place in the process leading up to the setting of health and social gain targets. The North Rhine-Westphalia case study captures this: “The mere discussion of target setting leads to the development of joint views, to the assessment of realistic fields of activity, and to the willingness of making compromises on hitherto controversial positions”. But there is evidence too that politicians of every hue would rather change “form” than really address “function”. And so the integrated care debate and the broader discussions about the need for intersectoral action become clouded at best, or sidelined at worst, while the reorganisations take place at regular intervals. The result? Health and social care workers become distracted and despondent. However, in pockets across Europe, examples are now occurring of the further application and expansion of network concepts and the formal development of virtual organisations.

Virtual reorganisation by design It is here that targeting features as the most critical element, as a mechanism for bringing people and organisations together. Figure 12.3 places the achievement of health and social gain at the local community level at its core – it provides the design purpose around which all else takes place. But, further, alongside the virtual organisations, it occupies the often neglected middle ground between policy and practice. Targeting and the associated virtual organisations constructed to achieve their requirements become the crucial elements in connecting policy and practice. I have coined the term “policy connect” to describe this. 177

HEALTH TARGETS IN EUROPE HIGH LEVEL HEALTH AND SOCIAL GAIN TARGETS

"POLICY"

LOCAL HEALTH AND SOCIAL GAIN TARGETS

"DESIGN PURPOSE"

"VIRTUAL REORGANISATION BY DESIGN (VRD)"

NATIONAL/REGIONAL STRATEGIC ACCOUNTABILITY

STRATEGY MANAGEMENT PRACTICE

STRATEGY MANAGEMENT PRACTICE

STRATEGY MANAGEMENT PRACTICE

NETWORK GOVERNANCE

NETWORKING

"PRACTICE"

Figure 12.3 design14

HEALTH SERVICES

LOCAL CITIZENS VOLUNTARY GOVERNMENT SECTOR

PRIVATE SECTOR

MANAGERIAL ACCOUNTABILITY

Intersectoral working through virtual reorganisation by

The negatives inherent in reorganisation can be reduced in this emerging arrangement. Representatives of the provider groups define current contributions to target action, exchange views and information, coordinate approaches, and decide on new initiatives. But managerial accountability remains within the existing organisations. Network governance plays a key role at all levels – strategy, management, and practice – and rules for engagement are set down. Across Europe many less formal arrangements have faltered: “virtual” has often been confused with “informal” and networks are assumed to be just a coming together of people with similar interests. Targeting, both in terms of its process and the requirement for results, is beginning to act as a powerful tool at the implementation level of health policy.

Conclusions: passing the “health flame” on Within Europe there is a growing acceptance at intergovernmental and national levels of the need for cohesive social programming and solidarity in what, in many ways, is a fragmenting world. In this regard, Dr Drago Najman, a former Deputy Director of UNESCO, in 1999 made a penetrating analysis. To précis, he said: The world is undergoing a period of transition to a new order.The framework we had has disappeared … The previous stability of the Cold War and nuclear 178

A EUROPEAN REVIEW

armaments is over.We could not have predicted the rise of China as a nuclear power, the fall of the Berlin Wall, or the rise and fall of NATO in less than a year … International law is being marginalised and so is the UN; and there is nothing to replace it … Centrally planned economies have been defeated; but the market economy is not solving our problems. Systems based purely on economic growth cannot be the central objective.21

Gro Harlem Brundtland, Director-General of the WHO, clearly supports this analysis and in a Year 2000 Reith Lecture,22 called for greater recognition that good health is a prerequisite for economic development or at least they must go hand in hand and together form part of the glue necessary to build global harmony. Neither of these two world leaders focused on the technical minutiae of health targeting, but called for leadership in development to achieve good health for all. At this level, “faith” is the important ingredient, justice the moral imperative, and peace and harmony the potential reward. But the same words are very often on the lips of politicians and are not too far from the minds of most others working in health and social care. However, as we have seen when looking at the examples of health target developments in various parts of Europe, technocratic and professional elements also come into play and these involve many games that are not altogether altruistic. Finally, of course, there are the citizens of Europe, all 850 million of them in WHO terms. Issues of personal survival and family protection rank high on their list of prerequisites. But, at base, they hope for life to be essentially fair and it is perhaps this interpretation of equity that binds people together. So, all have an incentive to pass the “health flame” along and it is perhaps now less surprising to see most major political parties in Europe targeting the reduction of inequity in all areas of health and healthcare provision, even though specific financing remains problematic. After 30 years of disparate efforts the various groups are coming together, guided by a mixture of self-interest and altruism. In this, nothing changes!

References 1 WHO Regional Office for Europe. Targets for Health for All: targets in support of the European Strategy for Health for All. Copenhagen:WHO Europe, 1985. 2 Treaty on the European Union 1993. 3 Treaty of Amsterdam 1999. 4 Council of Europe. Convention for the Protection of Human Rights and Fundamental Freedoms. 1953. 179

HEALTH TARGETS IN EUROPE

5 HMSO. Social Insurance and Allied Services (Beveridge Report). London: HMSO, 1942. 6 Sigerist HE. “Health” in Medicine and Human Welfare. New Haven, Connecticut:Yale University Press, 1941. 7 Drucker PF. The Practice of Management. New York/Evanston: Harper and Row, 1954. 8 WHO. Health 21 – health for all in the 21st century. Copenhagen: WHO Europe, 1998. 9 World Bank. World Development Report: investing in health. New York: Oxford University Press, 1993. 10 Suchman EA. Evaluation Research: principles and practice in public service and social action programmes. New York: Russell Sage Foundation, 1967. 11 Warner MM, New PKM, Pallan P. Towards a Health Centre Evaluation Model: A Reality Testing Process Approach. Vancouver: University of British Columbia and Health and Welfare Canada, 1976. 12 van Herten LM, Gunning-Schepers LJ. Targets as a tool in health policy: guidelines for application. Health Policy 2000;53:13–23. 13 Hedberg B, Dahlgren G, Hansson J, Olve NG. Virtual Organizations and Beyond. New York: Wiley, 1997. 14 Warner MM.Virtual reorganisation by design: an approach to progressing the public’s health in Wales using networks. In: Barnard K, Ed. The Future of Health – health of the future.A dialogue. London: Nuffield Trust on behalf of WHO, in press. 15 Lawless MW, Moore RA. Interorganizational systems in public service: a new application of the dynamic network framework. Human Relations 1989;42(12)1167–84. 16 Kickert WJ, Klijn EH, Koppenjan JFM. Managing Complex Networks: strategies for the public sector. London: Sage, 1997. 17 Provan KG, Sebastian JG. Networks within networks: service link overlap, organizational cliques, and network effectiveness. Acad Management J 1998; 41(4)453–63. 18 Campbell H, Hotchkiss R, Bradshaw N, Porteous M. Integrated care pathways. BMJ 1998;316(7125):133–7. 19 Selwood K. Integrated care pathways: an audit tool in paediatric oncology. Br J Nursing 2000;9(1):34–40. 20 Baker CD, Lorimar AR. Cardiology: the development of a managed clinical network. BMJ 2000;321:1152–3. 21 Najman D. Future of Europe in the light of geopolitical and economic developments. In: Barnard K, ed. The Future of Health – health of the future. A dialogue. London: Nuffield Trust on behalf of WHO, in press. 22 Brundtland GH. Health and Population. BBC Reith Lectures 2000: Respect for the Earth. http://news.bbc.co.uk/hi/english/static/events/reith

180

13: Values, beliefs, and implications MARTIN MCKEE

Introduction The concept of the state, or organisations acting on its behalf, setting targets for the health of its population presupposes a particular set of beliefs about how society should be organised. These beliefs are at the heart of the debate on the future of health policy. Does the state have a responsibility for ensuring that its citizens have access to affordable and effective health care? Or should this be a matter for individual responsibility as, if individuals value health care sufficiently to be willing to pay for it, then the market will respond in a way that makes that care available? What is the role of the state with regard to the major determinants of health, such as tobacco, alcohol, and nutrition? Are these simply a matter for individual choice or should the state recognise that, by its policies or lack thereof, it both influences and constrains choice about whether people smoke or not or what they eat? Are there universal answers to these questions or are the answers shaped by national context, such as values and beliefs? And how will the answers to these questions change in the future? Fundamentally, the development of policies based on health targets implies an acceptance of the principle of concern by governments for the health of their populations. Consequently, I begin by tracing the development of the welfare state and of the concept of solidarity in Europe, contrasting it with the situation in North America. I then explore some of the ideas underlying health strategies, looking at both the contribution of medical care and policies in other sectors to population health. My thesis is that European societies have deeply held beliefs that the state has a responsibility for the health of its population. The existence of these beliefs implies an acceptance of policies that seek to enhance population health. 181

HEALTH TARGETS IN EUROPE

The existence of a specifically European set of beliefs does not, however, preclude these beliefs being manifested in a number of different ways in different societies and with different degrees of development. Thus, a subsidiary question is the extent to which similar health policies are culturally acceptable in different societies and can therefore be applied in different settings. There are obviously many specific factors that need to be taken into account, such as the existence of institutions that can implement particular policies. My analysis will focus on the question of whether there is such a thing as a national cultural identity and whether this has any implications for a Europe wide health policy now and in the future. To do so I will explore possible future developments, asking specifically whether the idea of the welfare state is sustainable in Europe. I will also look beyond the state, to ask what role might be played by supranational bodies, such as the European Union and the World Trade Organization.

The future of the welfare state: how did we get here and where are we going? The development of health targets presupposes a collective rather than an individual approach to health policy. In Europe this is manifest in the welfare state. I therefore begin by tracing how the welfare state (particularly in respect of health care) has developed in Europe and describe the institutional frameworks within which health care now exists. I will also contrast Europe with the USA, a country that has often provided a point of reference for healthcare reformers, in the attempt to discover an essentially European approach to all these matters. I conclude by speculating on how the principles underlying health care in Europe might change in the future. A concern by the state for the health of its population has only emerged relatively recently. There were always some exceptions, such as the need to ensure that the ruler could call upon sufficient men with the necessary strength to provide an army in time of war. Indeed, it was the inadequate condition of recruits during the Boer War that stimulated the British government to pass one of its earliest pieces of universal social legislation, the 1902 Midwives Act.1 Some states had, however, been taking a growing interest in the health and welfare of their populations since the mid 1800s. The reasons remain controversial.2 Some saw the goal of social solidarity as instrumental, a means by which the state could secure legitimacy. 182

VALUES, BELIEFS, AND IMPLICATIONS

Thus, the early reforms were forced on the ruling class by the twin threats of contagion – cholera and communism – that stalked Europe in 1848.3 Others argue that health and welfare became an intrinsic goal, with rulers driven to some extent by altruism. Whatever the reasons, health and welfare policies, indeed welfare states, spread across Europe, to the extent that all countries have now established some system that provides for universal coverage by health care, a model that is quite different from that in the USA. The development of welfare states in Europe and their determinants have been explored in depth by Flora and Alber.4 The spread of healthcare coverage was slow, from its beginnings in the coverage of industrial workers in Germany in the second half of the 18th century to the inclusion of agricultural workers in some countries, which only took place in the 1960s. Drawing on a wide range of data sources, they show how the differing pace of industrialisation and urbanisation affected countries at different times. But each country, at some time, faced the challenges arising from new working conditions and income insecurity from the breakdown of traditional support systems. The timing of introduction of social insurance reflected a combination of the pressures of social change and the strength of political parties that represented the interests of the working class. It was facilitated by a broadening of suffrage and an existing well developed state bureaucracy, commonly found in countries with a strong monarchy that had cause to use such a bureaucracy to maintain control. There are several schools of thought that seek to explain these developments. Durkheim’s analysis is particularly helpful, describing how the nature of social cohesion was changed by the process of industrialisation and, specifically, division of labour.5 Pre-existing social support systems, which he described as mechanical, that were based on relationships within agrarian societies, were replaced by new systems of structural interdependence, which he called organic solidarity, in which each individual was dependent on the functioning of different elements of society as well as overall societal cohesion. The consequences of the initial failure by western societies to make this transition is shown by the worsening health of the English working class in the 18th century, whose conditions were described graphically by Engels.6 However, it has recently become clear that the consequences for those in developing countries, many of whose traditional systems were destroyed by colonising powers, were even greater. Communities in India and China that had withstood climatic threats in the late 1700s 183

HEALTH TARGETS IN EUROPE

were devastated by them in the late 1800s.7 Thus, it is apparent that, in the context of a move away from traditional agrarian societies, some form of collective response to health was essential. In Europe, the extension of the welfare state accelerated after the second world war, encouraged by the shared experience of hardship that had affected entire populations, as well as by a reaction to the political extremism that had contributed to the onset of war. These circumstances did not, however, apply in other parts of the world that had not shared these experiences, such as North America. While the extension of coverage was a universal phenomenon in Europe, the precise mechanisms varied between countries. Essentially, health care could be organised in one of three ways: markets, associations (free groupings representing collective interests), and state bureaucracies. In continental Europe, state bureaucracies developed earlier in Protestant countries while associations played a greater role in Catholic and mixed countries. These different approaches shaped the institutions that emerged, in particular the choice of social insurance, organised through associations of employers and trade unions, or national health services, organised through state bureaucracies. A subsequent factor was the transition to democracy in Spain, Portugal, and Greece in the 1970s, where the creation of national health services was viewed as a symbol of a break with the past.8 In contrast, a different philosophical tradition prevailed in Anglo-Saxon countries. 9 While the continental model envisaged human rights as based on mutual relationships that provide the preconditions for individual development and self-realisation, Anglo-Saxon philosophy emphasises the right to freedom from interference by others.10 As shall be seen, this difference is important in understanding the diversity in social policy among industrialised countries, with continental Europe occupying one end of a spectrum and the USA the other, with countries such as the UK, Canada, and Australia somewhere in the middle. The UK does, however, illustrate why it is necessary to look at each of the dimensions of belief systems. While its dominant values tend to occupy a position midway between continental Europe and the USA, the definition of jurisdictions and logic of regulation are quite different from those in the USA so that, within a relatively individualist culture it has developed wide ranging health strategies that engage a broad range of sectors.11 This position has recently been developed by Giddens as the concept of the “Third Way”.12 Writing on the related topic of child welfare, Pringle has suggested that this may be because societies with more conflictual features, 184

VALUES, BELIEFS, AND IMPLICATIONS

such as the UK, may be more open about the extent of their social divisions.13 In contrast, societies where there is a stronger commitment to the ideals of social cohesion may find it more difficult to address them.This view gains support from comparisons of policies on social and ethnic inequalities where the scale of the challenges have been well documented, if inadequately resolved, in the UK but have received very little attention in countries such as France14 or Germany. For the present purposes, however, the key point is that politicians of all parties in Europe have shared a common vision of social solidarity, albeit with certain differences in how it is conceptualised and using different models to develop comprehensive systems. In doing so, they have sustained a high degree of popular support for certain basic collectivist beliefs. In North America, in contrast, many of the forces for change were much weaker and the spread of coverage was much slower. Canada only achieved universal healthcare coverage in 1972 and the USA has still not succeeded in doing so. The reasons for this failure by the USA to ensure healthcare coverage for its population, as well as its consequences for health, should be understood by Europeans because of the major influence that American ideas continue to have on health policy makers in some European countries. Thus, concepts such as diagnosis related groups and managed care (however imperfectly understood) have migrated rapidly across the Atlantic, contrasting with the lack of awareness of developments in Europe (or even in Canada) by many American policy makers and their imperviousness to European concepts such as integrated primary care or equity.15 A comparison by Kudrle and Marmor of the USA and Canada sheds some light on the failure of the USA to achieve universal coverage.16 They identify the different cultural values in the USA and Canada, with, as already noted, the former being much more strongly individualistic. This is manifest in many ways. Thus, the USA has never developed a successful socialist party. It is also seen in its adherence to the right to bear arms, despite the enormous annual toll of avoidable death that results. Another, perhaps more important, factor is the rigid separation of powers in the US system, making incremental change very difficult and providing many opportunities for strong vested interests to block change. Thus while there is widespread dissatisfaction in the USA with the healthcare system,17 a situation that contrasts with high approval among Canadians for their system, which is even seen as a defining national characteristic,18 effective reform has been impossible. 185

HEALTH TARGETS IN EUROPE

The consequences of this failure are profound. Despite spending much more per head of population than European countries for health care (in fact, even public expenditure on health in the USA is now greater than in European countries), over 43 million Americans have no healthcare coverage.19 Although health care is only one of the factors determining population health, and the wide income inequalities, low literacy levels, and high levels of violence in the USA also play a major role, lack of access to health almost certainly contributes significantly to the low level of life expectancy in the USA compared with Europe.

From solidarity to targets for health The evolution of the welfare state in Europe can thus be seen as part of a wider social process, embedded in the concept of social solidarity. The architects of the resulting systems were concerned primarily with coverage. The effectiveness of what was being provided was largely assumed. By the last quarter of the 20th century this assumption was being challenged. In a seminal work in the mid 1960s, McKeown argued that health care contributed very little to population health.20 Drawing on data from the 19th to the mid 20th century, he contended that the improvements in health that had occurred were attributable primarily to improved living conditions. At the same time, the optimism of the medical profession, who had predicted the “conquest” of cancer and of infectious disease, was challenged by events such as the thalidomide affair. Illich coined the term “iatrogenesis”, arguing that much of modern health care was not only useless but harmful.21 By the 1980s a consensus was emerging that the true answer lay somewhere between the extremes of optimism and pessimism. It was clear that health care had the potential to improve population health but it did not always do so. Interventions of known effectiveness were underused and those of dubious effectiveness, or even harmfulness, were used widely. In addition, there was an emerging view that health professionals could not ignore the broader determinants of health. Recognising that others would have to implement appropriate policies, a consensus emerged that health professionals had a role to play in quantifying the threats to health and advocating effective responses, with notable early examples being several influential reports on smoking. Thus universal healthcare coverage was seen as a necessary but not sufficient condition for improved population health. This view arose 186

VALUES, BELIEFS, AND IMPLICATIONS

in a political context in which there was a shared acceptance that improved health was a legitimate goal of government policy. Some countries took longer than others to accept this view. One was Denmark, which had pursued strongly individualistic policies since the 1960s. By the early 1990s, however, it became apparent that Danish life expectancy had stagnated, falling from close to the top of the European Union ranking to near the bottom. Belatedly, the Danish government developed and implemented a wide ranging health strategy in response.22 In passing, the evolution of Danish policy on health illustrates the importance of considering dominant belief systems within countries. Denmark lies geographically on the interface between the “continental” countries such as Germany and the Nordic states such as Sweden, drawing on the values of both. Governments and those acting on their behalf have thus sought to promote several complementary agendas. One is a greater emphasis on identification of unmet need for health care and thus on redressing inequalities.23 The second is the promotion of effective care. This has several elements. One is an increased investment in research and development.24 A second is ensuring that what is already known is implemented, one example being the Cochrane Collaboration, in which researchers synthesise and disseminate the results of existing studies.25 These activities have come together within national and regional health strategies. These involve identifying the health needs of a population, attempting to choose goals that are realistic but achievable as well as both relevant and measurable. Attention to population health and, ultimately, to targets for health has, however, proceeded at different rates across Europe. One factor has been the system of healthcare financing.While social insurance and national health services both ensured universal coverage they differed in a fundamental respect. Social insurance funds were responsible for a population defined on the basis of membership of the fund. Health authorities within a national health service were responsible for a population defined in terms of residence in a geographical area. Consequently, health authorities tended to adopt a population rather than an individual perspective somewhat earlier than social insurance funds. In addition, they tended to have stronger links with other sectors that had an influence on health, such as transport, employment, and environmental health. Thus, national health services had infrastructure and links in place that facilitated policies based on targets for health. The WHO has played a key role in promoting the concept of health targets, with the Regional Office for Europe launching 38 targets for 187

HEALTH TARGETS IN EUROPE

Health for All by the Year 2000 in 1984.26 More recently, the European Regional Office has created a new package of targets within its Health 21 policy.27 The WHO’s targets had some impact, stimulating European countries to reassess their health strategies and, in many cases, to set their own targets for health improvement. This impact was, however, limited at least in part because of a lack of consensus on the legitimate role of a state in setting and implementing policies to achieve health targets. To some extent this was because of a failure to engage in a necessary debate about belief systems in different countries. The WHO has now placed itself in the centre of this debate through its publication of the 2000 World Health Report.28 The report has received considerable attention as a result of the controversial rankings of the performance of national health systems. This has somewhat overshadowed its other messages, one of which is the concept of stewardship, which is central to the argument about a government’s role in health policy. Stewardship is the role that governments play in ensuring the welfare of their populations.29 It requires health ministries to oversee and guide the functioning and sustainability of the healthcare system, as well as wider policies that influence health. It encompasses six elements: overall system design, performance assessment, priority setting, intersectoral advocacy, regulation, and consumer protection.30 Health targets seem clearly to fit within this framework. Unfortunately, as the authors of the World Health Report note, progress has been extremely uneven. They contend that stewardship has failed in many countries and identify three specific failings, which they illustrate by analogy with impairments of vision. The first is myopia, with health ministries losing sight of their main target, which is improving the health of their populations. Their myopia also limits their ability to look into the future and thus to invest adequately in the future needs of the health system. The second is tunnel vision.This causes ministries to seek refuge in creating legislation, with scant regard for how it is implemented and enforced. Effective stewardship thus requires development of an appropriate mix of incentives and regulations, directed at the full range of actors that have a part to play. The third failing is turning a blind eye to the failure of policies to achieve results. This implies a role for monitoring, evaluation, and adaptation of policies to changing circumstances. All of these failings have implications for the development and implementation of health 188

VALUES, BELIEFS, AND IMPLICATIONS

targets and indicate areas in which the capacities of governments need to be reviewed. Criticisms of the 2000 World Health Report have been twofold. One set relates to the data and the methods used, in particular the ways in which gaps in the data were handled. A second set relates to the implicit values, arguing that it is wrong to assume a set of universal health system goals.31 The report has, however, placed the responsibility of the state for the health of its population firmly on the agenda, echoing Oscar Wilde’s remark that “there is only one thing in the world worse than being talked about, and that is not being talked about”.32 This, in itself, should be welcomed as a first step in making explicit the goals that are being pursued by those involved in the development and implementation of health policies. These goals will inevitably reflect underlying values. What is known about these values and to what extent are they similar in different countries?

Values and beliefs Contandriopoulos and colleagues have argued that health policies are shaped by a country’s dominant belief system.33 This goes beyond the simple dichotomy of individualist versus collective policies. The elements of a dominant belief system can be thought of as being grouped around four poles or concepts: values; understanding of phenomena; definition of jurisdictions and allocation of resources; and logic of regulation.34 Each of these has implications for how the concept of health targets is understood and the legitimacy that is given to it. Values include the balance between equity and individual autonomy and thus are central to the debate about health targets. At the risk of simplification, the range of values can be encapsulated by three broad principles that concern the way resources should be distributed within society. One principle is that health care should be distributed according to one’s contribution to its cost.35 Publicly funded care should be kept to the absolute minimum. This, to varying degrees, is the principle underlying the different elements of the US healthcare system. A second principle is that the provision of care should take account of reward, in other words certain groups in the population can earn an entitlement to care by virtue of their contribution to society (such as the elderly) or their behaviour, in not engaging in unhealthy activities.36 The third principle, which underpins the modern welfare state in most European countries, sees resources being distributed according to need. Every member of society should have an equal 189

HEALTH TARGETS IN EUROPE

chance of success. Inequalities are accepted but only to the extent that they enable the least fortunate to benefit.37 In passing, it should be noted that social justice is only one of the reasons why health services should be financed collectively. The other is the gain in efficiency that arises from collective financing.Thus, it makes little sense to wait until one is ill to decide that it is time to build a hospital. Understanding of phenomena relates to how concepts such as life and death, sickness and health are interpreted. This has implications for how the goals of a healthcare system are viewed.38 Thus, should health targets focus on mortality or disability and how should different outcomes be combined? Even when using standardised descriptions and methods, the significance of particular diseases varies between different societies.39 This is especially relevant when individuals concerned can be thought of as having some responsibility for their condition or, conversely, are viewed as “innocent victims” of the actions of others. Definition of jurisdictions and allocation of resources encompass the way in which the healthcare system and those working in it are perceived, as well as the allocation of resources between prevention and cure and between health care and broader determinants of health. Although related, this is different from values as it determines which, of the many possible actors, can legitimately pursue health targets. The logic of regulation describes how society chooses to regulate the delivery of health care and related policies, which may be technocratic, professional self-regulatory or market based.33 In different combinations, these concepts give rise to myriad sets of beliefs. Only some are consistent with the view that the pursuit of health targets is legitimate. Within them, different combinations shape the nature of targets that will be pursued and the instruments and actors that can be used in this process. Of course, the concept of a dominant belief system does not imply a single view held by all members of a society. Furthermore, beliefs can change over time, as shown by the fluctuating strengths of political parties, and very occasionally, as in 1989–91 in central and eastern Europe, quantum changes can occur. Nonetheless, the tension and negotiation that exist between various values and beliefs usually confer a degree of stability. There is a wealth of anthropological and sociological literature on the diversity of values and understanding of phenomena between countries.This diversity is often visible in the different rites associated 190

VALUES, BELIEFS, AND IMPLICATIONS

with, for example, birth and death. However, many difficulties emerge when one seeks to apply this information to national policies, such as implementation of targets for health. The first question is whether the phenomenon of national identity has any intrinsic meaning.40 Several 18th century writers, notably Montesquieu and Rousseau, had little doubt that it did, with Rousseau remarking: “The first rule which we have to follow is that of national character: every people has, or must have, a character; if it lacks one we must start by endowing it with one”.41 In contrast, Marx saw little role for environmental and cultural factors, instead arguing that societal developments are shaped primarily by changes in the means of production and the nature of class conflict.Where a national identity existed at all it was an artificial construct.This argument was developed by Hobsbawn, who contends that many of the outward symbols of national identity are “invented traditions”,42 created by elites who drew on an idealised past to convey a sense of continuity where none exists. Hobsbawn can produce many examples in support of his thesis, in particular in the development of national identity in the successor states of the Austro-Hungarian empire, many of whom sought to trace their origins to diverse ethnic groupings from the Roman period or before. However, as Smith has noted,40 this analysis fails to explain many well recognised phenomena. In contrast, Weber accepted the existence of national identities that had been shaped by common social experiences, political memories, and the contribution of intellectuals who preserved the “irreplaceable cultural values” of a nation.43 Durkheim also recognised national identities, in his case emphasising the contribution of religion and its associated symbolism to values.44,45 For most people, however, the concept of national identity draws not from these academic treatises but rather from their experience of the world about them.There seems to be a vast amount of evidence to support the concept of distinct national identities, ranging from tastes in popular culture (exemplified by television compilations of programmes from elsewhere that appear bizarre or mystifying to an audience unfamiliar with them) to differences in diet (although here the delightful diversity of Italian regional cuisine tends to support Metternich’s remark that “Italy is a geographical expression” rather than a natural political entity). These superficial appearances must, however, be treated with caution lest they lapse into cultural stereotyping. In addition, as the 191

HEALTH TARGETS IN EUROPE

example of Italy indicates, the acceptance of the concept of a national identity is not incompatible with other identities, whether regional, ethnic or religious, being nested within it. For the present purposes, however, as health policies tend to be developed at the level of the state, it is appropriate to focus primarily on the concept of a national belief system. The implications of national systems of beliefs for health policy have, however, typically remained at the level of anecdote and speculation. Why is it that Belgian drivers kill each other at a rate twice that in the Netherlands? Why has Denmark rejected many of the regulatory policies, such as a monopoly on retail alcohol sales, that are accepted in Sweden even though, as a result, it has seen its life expectancy fall progressively behind that of Sweden? Why have the individualistic British been willing to accept cameras to identify speeding drivers while Swedes reject them? For the present purposes, there is sufficient evidence of national differences in beliefs to assume that health policies developed in one setting will not necessarily work in another. Unfortunately, the knowledge required to judge whether a particular policy can be transplanted from one setting to another remains fragmentary, in part because knowledge of the beliefs that legitimise such a policy remain so poorly understood. A structured approach to lesson drawing, in which the policy maker is clear about the goal being pursued and the model of cause and effect that is implied, can do much to enhance the success of policy transfers.46 However, a key issue is the need to consider carefully how beliefs in one’s own country might influence the adoption of a policy developed elsewhere. The challenge is compounded by the potential for beliefs to change, notwithstanding their relative stability referred to earlier. McNeill has argued that the existence of national identities was a transient phenomenon that emerged in western Europe at the end of the 18th century and which will disappear early in the 21st century.47 This raises a further set of questions. If unique national identities do exist, to what extent are they breaking down in the face of migration, with its ensuing multicultural societies, regionalisation, and other forms of fragmentation on grounds of gender or membership of a definable group? Finally, how is national identity changing in the context of the creation of supranational identities such as the European Union and of globalisation? 192

VALUES, BELIEFS, AND IMPLICATIONS

The future The current situation in Europe is that there is a broadly based consensus in favour of healthcare systems that provide universal coverage, based on the principle of solidarity. There is also a growing acceptance that health systems should do more than simply meet expressed demand. Instead, they should assess health needs, in particular those that are not being met, and ensure that effective policies are provided equitably to meet them. This view has been translated, in many European countries, into policies that incorporate explicit targets to improve health, although there is still much to be done to take them beyond the aspirational to a point where they have a significant impact on health.48 What will be the context within which health policy makers work in the future? Will the environment be conducive or obstructive to strategies involving targets for health? Only a fool or a charlatan would claim to be able to predict the future with certainty.49 As Popper has noted, the future depends on discoveries we have not yet made and is therefore unknowable.50 Nonetheless, with caution and humility, some of the issues that may influence the future can be identified. Those who wish to explore some of them in more detail may consult a recent report by the British Government’s Foresight Panel that addresses the future of health care.51 I select two here for more detailed exploration. These are, first, the future of the welfare state in Europe and, second, the impact of supranational influences, whether acting at a global or regional level.

Crisis in the welfare state? The emergence of social support systems, not only in health care but also in areas of unemployment and pensions, has formed part of a European postwar consensus. This was, however, challenged in the mid 1970s. There were several reasons but one of the most important was the economic shock imposed following the 1974 Middle East war, which lead to a substantial increase in oil prices and a worldwide recession. In the 1990s the pressures on public finances imposed by the convergence criteria for joining European Monetary Union became an important factor. Another pressure has been the challenge of the postindustrial society. The traditional model of employment and family life, in which male industrial workers were in lifelong employment, supported by 193

HEALTH TARGETS IN EUROPE

non-working wives, is declining everywhere. Countries have differed in their responses,52 Nordic countries emphasising lifelong learning and retraining but maintaining a safety net for the unskilled through public sector employment while Anglo-Saxon countries, such as the UK, have reduced unemployment benefits and pushed the unemployed into lowpaid and often informal jobs. Continental European countries have emphasised early retirement. Each of these has consequences for revenue collection and expenditure and thus for the sustainability of the welfare state. Politicians began to fear that their systems would be unsustainable but, in fact, they adapted. A wide range of cost containment strategies was put in place and, although initially they had varying degrees of success, by the 1990s European countries had stabilised expenditure on health care as a percentage of national wealth.53 The mechanisms varied but many involved some form of market based reforms. Some tax based systems, such as the UK and Sweden, introduced a separation between purchasers of health care and those who provided it.54 Some countries with social insurance systems, such as Germany, introduced competition between insurance funds. Many countries increased direct payments by patients, by removing certain drugs from the list of those that can be prescribed or by introducing copayments for certain services. Some also sought to increase the amount of care provided by the private sector.55 While many other factors played a part, including shortages of key workers because of demographic changes and rising public expectations, these policies were linked, by the media and ultimately by health professionals and the public, with a decline in the quality of care in some countries. This was particularly true for countries with tax funded systems that had tended to spend less on health care than did social insurance systems. By the late 1990s there was evidence of a backlash in many countries. The UK, which had been in the forefront of market based reforms, largely abandoned them. A British civil servant has noted that “the British public’s sense of justice and fairness was not consistent with the concept of maximising private advantage that underlies the competitive model.”56 In France, the government stepped in to limit a system that had permitted physicians in certain areas to charge higher fees.57 In Germany a new Social Democrat led government reversed many of the procompetitive elements introduced by its predecessor.58 194

VALUES, BELIEFS, AND IMPLICATIONS

The changing perceptions underlying these policies have been described in detail in Sweden by Bergmark, who plots changes in attitudes to the public sector throughout the 1990s.59 A period of relative affluence in the early 1990s was accompanied by a majority of the population favouring a reduction in public sector expenditure but, by the late 1990s, when the quality of services had deteriorated visibly, this changed, with more people favouring an increase in expenditure. In parallel with these developments, economists and political scientists have been drawing lessons from the experiences of some of the former socialist countries, in particular those emerging from the USSR. There, existing systems were swept aside by markets with calamitous consequences for health, as well as for economic development. The central message to emerge from this experience is that while markets may have a place in social policy they must be embedded within a strong institutional framework.60 There are, however, some concerns on the horizon. As already noted, the price of cost containment in some European countries has been a decline in quality of care. This could have the effect of encouraging the wealthy to opt out of the public system, as has already happened with education in large parts of the UK. This risk has been recognised by some governments, with the UK injecting a large increase in funds into the National Health Service.61 In others, such as Sweden, there remains concern that this will undermine even quite strongly held principles of solidarity.62 While these concerns demand attention and appropriate responses, they do not suggest that the European welfare state is in crisis. The values underpinning it appear to be held strongly and while they may fluctuate from time to time they do appear to be relatively stable. Indeed, although certain politicians have advocated such policies from time to time, it is noteworthy that no European country has been able to make the fundamental changes to the healthcare system such as those imposed by Pinochet in Chile, which had such disastrous consequences.63 Thus, predictions of the demise of the welfare state in Europe seem somewhat premature.

The wider European context The second issue to be considered is that of the broader international context. Within Europe, two bodies may have a potential impact on health policy: the Council of Europe and the European Union. 195

HEALTH TARGETS IN EUROPE

The Council of Europe is an older and substantially larger body than the European Union, with which it is sometimes confused. Since 1990 its membership has expanded beyond western Europe to include many of the former communist bloc countries, including Russia. The European Convention on Human Rights was agreed by the Council of Europe in 1961 in response to the abuses of the second world war and provides a basic set of rights for the people of Europe.64 The European Convention sets out a basic framework of 14 categories of human rights. Only one, the right to freedom from torture, inhuman or degrading treatment, is absolute. The rest are subject to qualifications, of varying degrees of latitude.Thus, the right to liberty is constrained by the ability of the state to detain those of “unsound mind”. Although none of the rights relates specifically to health care, several have consequences for its delivery, especially in areas such as the right to accept or refuse treatment. The implications of the Convention for health targets remain unclear and there is little relevant case law on which to draw. It has, however, been argued that a failure to provide treatment of an acceptable standard could leave a healthcare provider open to challenge because of the prohibition on inhuman and degrading treatment, where a plea of inadequate resources would prove no defence.65 A growing awareness of the scope of the Convention among lawyers and the public may, however, encourage more challenges to existing ways of delivering health care on grounds of human rights. A second body of international law has arisen from the creation and development of the European Union. The scope of European law has extended considerably since the Treaty of Rome. Successive treaties and, more importantly, rulings by the European Court of Justice have built on the principles of creation of an ever closer union and freedom of movement of goods, services, people, and capital, affecting many aspects of the delivery of health care.66 Health featured to only a limited extent in the Treaty of Rome, which contained provision for occupational health services for workers in the coal, steel, and atomic energy industries. Provisions on free movement of people did, however, lead to the promulgation, in the 1970s, of various directives on mobility of health professionals and on the right to treatment in countries other than that in which one was resident. The 1985 Single European Act introduced the principle that a high level of health should be a goal of Community 196

VALUES, BELIEFS, AND IMPLICATIONS

policies in certain areas. This was subsequently used to justify the establishment of programmes such as Europe against Cancer and Europe against AIDS. Such policies, which were seen by some national governments as stretching the competence of the European Union beyond what had been agreed in the treaties, led to a degree of retrenchment and the introduction of the concept of subsidiarity. The European Union did, however, gain a formal competence in health with the ratification of the Maastricht Treaty, article 129 of which provided for limited powers in the field of public health. However, it also reiterated that the organisation of healthcare services remained the responsibility of member states. This view was welcomed by many governments. The most effective policies to constrain the growth in healthcare expenditure had been based on limiting supply.Thus, certain services might not be available at all or only after a period of waiting. If their citizens could obtain these services in a neighbouring country and demand that the cost should be met by their sickness fund or health authority, then these policies would be undermined. Until recently, it was assumed that patients did not generally have such rights. Although existing directives did permit individuals to have the costs of treatment in other countries covered, this was in strictly limited circumstances.The main provision was for those taken ill while abroad, with other provisions covering those whose work required them to travel between countries. Travel abroad to receive treatment for a pre-existing condition was possible but if it was to be covered by the patient’s healthcare system then it would have to be agreed in advance. This situation was first challenged by two rulings of the European Court of Justice in 2000.67 The Kohll and Dekker rulings related to citizens of Luxembourg who obtained health services abroad.The two individuals argued successfully that their sickness fund, in Luxembourg, was obliged to reimburse their expenses as it would otherwise be imposing an illegal barrier to freedom of movement, even although they had not received prior authorisation to obtain treatment abroad. While some governments immediately took action to make it easier for their citizens to obtain treatment abroad, others took the view that action was not required because of certain aspects of the Kohll ruling, which related to orthodontic treatment.68 The Court ruled that an orthodontist works “outside any hospital infrastructure” and so provides a “service”. Article 39 does preclude 197

HEALTH TARGETS IN EUROPE

any action that makes provision of a service more difficult between member states than within member states. This does not necessarily mean that services must be reimbursed but failure to do so de facto makes obtaining that service more difficult. A key question is whether other health services are “services” within the meaning of the treaties. In most cases they are not as long as they are part of a national health system and not provided for remuneration. This principle can be illustrated by reference to one of the exceptions. Ireland, where abortion is illegal, sought to ban advertisements for British private clinics that were appearing in magazines circulating in Ireland. This was ruled unlawful because the clinics were offering a service, outside the formal British healthcare system and for remuneration. In the Kohll case the Luxembourg government argued that free movement of services could be blocked where it would undermine the financial basis of the social security system involved or restrict its ability to provide care to its home country population. The Court accepted this argument but held that as M Kohll had only asked for what a Luxembourg dentist would have charged, this could not be the case. A second argument was that the Luxembourg authorities needed to be able to authorise treatment so that they could protect public health, specifically the safety and efficacy of treatment. This was rejected as dentists practising anywhere in the EU are considered to have met the same professional standards. In summary, the Court rejected the right of a healthcare payer to contract selectively so as to ensure quality by means of a blanket policy on nationality. It did, however, constrain the scope of any requirement to reimburse treatment to those areas of health care that are delivered outside hospitals or other components of what might be considered the formal healthcare infrastructure. Several of these uncertainties have now been resolved in two rulings relating to Dutch patients obtaining treatment abroad. In these cases, the rulings did involve hospital treatment, which the Court clarified does count as a service. It stated that authorisation for treatment abroad could only be refused if the treatment was ineffective, if providing treatment abroad was on such a scale as to undermine the home system, or if equally appropriate treatment could be provided in the home country without undue delay. These rulings have greatly extended the European dimension to health care and have caused those governments that had ignored the Kohll and Dekker rulings to take action. 198

VALUES, BELIEFS, AND IMPLICATIONS

Perhaps more importantly, they serve as a reminder that a European healthcare policy is emerging, albeit as a result of disconnected Court rulings dealing with specific issues. As a consequence, there are growing calls for a statement of fundamental beliefs in relation to health care in Europe that would provide some context for rulings that otherwise are based primarily on internal market considerations. While these Court rulings have attracted a great deal of attention, they are somewhat peripheral to the development of health policy at a European level. In the context of health targets, the main influence is likely to be the European Union’s public health strategy. This emphasises the importance of timely and valid information on health and the benefits of sharing experience. At present there are many gaps in the information systems in European countries. In particular, data on variations within populations, in relation to ethnicity or socioeconomic status, are often lacking. Ultimately, enhancing the information base and sharing experiences are likely to make a major contribution to the capacity of the relevant bodies in Europe to develop, implement, and monitor effective policies to improve the health of their populations.69 The Commission’s public health strategy is not set in stone. The creation of a new Directorate General, DG Sanco, has given a boost to public health within the Commission but, at the time of writing, there remains uncertainty as to how its role will evolve. One possibility is that, in the face of a succession of threats to food safety, such as the recent outbreaks of foot and mouth disease in the UK, it will concentrate its efforts on the integrity of the food supply chain. This would be consistent with the narrower interpretation of the role of the European Union subscribed to by some countries, that would seek to limit it to matters directly concerned with the single market. An alternative interpretation envisages the European Union developing policies on the wider determinants of health. Both visions can, arguably, be justified by the somewhat ambiguous wording of the Treaty.70 If the European Union was to develop policies addressing broader public health issues, what should be their priorities? They may wish to be guided by a major consultation undertaken on their behalf by the Société Française de Santé Publique in 1999.This sought a consensus on the major challenges to health requiring concerted action at a European level, exploring differences in understanding of terminology and of how issues are perceived in each country.71 This involved a two-stage process, with consensus development initially at national 199

HEALTH TARGETS IN EUROPE

level and then at a European level. The issues identified were health inequalities, alcohol, tobacco, illicit drugs, health surveillance systems, quality in health care, ageing, mental health, the environment, and food and nutrition. The policies needed to address these issues have been described in detail elsewhere.72 Closer European integration is also likely to influence the delivery of health care more indirectly.The Treaty provisions on free movement of persons have expanded greatly the opportunities for people to move between countries for extended periods. In this respect pensioners form an important group. By virtue of their age they are more likely than most to use healthcare facilities. The ability to draw their pensions in other countries, together with increased ease in purchasing property, means that increasingly large numbers are retiring to other countries, especially to southern Europe. Even before the recent Court rulings on movement of patients, many people were in a position to compare the experience of health care in two jurisdictions. Given the variation in, for example, the quality of facilities or waiting times, this will inevitably have an impact on expectations, creating pressure to improve standards in those systems judged to be performing poorly. This process will be encouraged by the greater interchange of information on health system performance. Thus, the recognition that cancer survival in the UK lagged behind that in the rest of western Europe was a major factor in the British government’s decision in 2000 to increase healthcare spending substantially.61

The wider world Speculation as to the future of health policy must take account of the forces of globalisation. Unfortunately this is far too large a topic to address in any detail here, except to note that health policy makers face major challenges in identifying and responding to the threats that it poses as well as taking advantages of the opportunities that it provides.73 Instead, the concluding section of this chapter will examine the role of the World Trade Organization (WTO). One of the main issues being addressed by the WTO is the General Agreement on Trade in Services (GATS).74,75 Pressure for the inclusion of health is coming, largely, from the American healthcare industry, which is now unable to sustain its phenomenal growth in the 1990s76 and thus is seeking overseas investment opportunities. These can only be realised by opening up markets through mechanisms such as GATS but, to achieve levels of profitability comparable to those in the US, this 200

VALUES, BELIEFS, AND IMPLICATIONS

would also require policies that would select low risk individuals, thus undermining existing solidarity. The development of GATS in the field of health care creates important concerns as it is not at all clear that, left to itself, the WTO will follow the European Court of Justice’s view that health care is, in most cases, not to be seen as a commercial service.77 Nonetheless, as the debate within the WTO attracts increasing attention from the European health policy community, it is clear that the nature of the discussion is changing, with internal WTO documents conceding that trade considerations must be balanced by equity and social justice. This debate is, however, far from being resolved and its conclusion is likely to be of considerable importance for health policy in Europe in the 21st century.

Conclusion In this chapter I set out to determine whether there were specific values and beliefs in Europe that would make policies based on health targets more or less likely to succeed. Specifically, I sought to define how such values differ from those in North America, and in particular the United States, because of the substantial influence that that country has had in defining the nature of the debate on health policy in Europe. I also explored how such values might be challenged by future developments, particularly at a supranational level. I have concluded that there are identifiable European values and beliefs, in particular an emphasis on inclusiveness and social solidarity. This does not, however, mean that there is a single European perspective. On the contrary, there is a great diversity, although within certain generally agreed boundaries.This diversity is grounded in each country’s political, cultural, and religious inheritance but is still inadequately understood. A belief in solidarity, when coupled with growing acceptance of the need for policies that enhance equity of access and promote effective care, provides a receptive environment for strategies based on health targeting. Looking to the future, while any judgement is inevitably speculative, it appears that rumours of the incipient demise of the nation state as a player in health policy are greatly exaggerated. Closer European union is likely to raise awareness of differences in policies and outcomes and thus encourage a more uniform, and better, approach to common problems. In the end, however, it will continue to be regional and national governments that have to implement these policies. 201

HEALTH TARGETS IN EUROPE

Acknowledgements I am grateful to Charles Normand, Ann-Marie Rafferty, and Marshall Marinker for helpful comments on earlier drafts. References 1 Porter D. Health, Civilisation and the State. London: Routledge, 1998. 2 Jessop B. State Theory: putting capitalist states in their places. Cambridge: Polity Press, 1990. 3 Porter R. The Greatest Benefit to Mankind. London: HarperCollins, 1999. 4 Flora P, Alber J. Modernization, democratisation, and the development of welfare states in Western Europe. In: Flora P, Heidenheimer A, eds. The Development of Welfare States in Europe and America. New Brunswick, NJ: Transaction Publishers, 1982. 5 Durkheim E. The Division of Labour in Society. Basingstoke: Macmillan, 1984. 6 Engels F. The Condition of the Working Class in England. Harmandsworth: Penguin, 1987. 7 Davis M. Late Victorian Holocausts. London: Verso, 2000. 8 Figueras J, Mossialos E, McKee M, Sassi F. Health services in southern Europe: is there a Mediterranean paradigm? Int J Health Serv 1995;5: 135–46. 9 Berlin I. Four Essays on Liberty. London: Oxford University Press, 1969. 10 Mill JS. On Liberty. London: Parker, 1859. 11 Fulop N, Elston J, Hensher M, McKee M, Walters R. Lessons for health strategies in Europe: the evaluation of a national health strategy in England. Eur J Public Health 2000;10:11–17. 12 Giddens A. The Third Way: the renewal of social democracy. Cambridge: Polity Press, 1998. 13 Pringle K. Children and Social Welfare in Europe. Buckingham: Open University Press, 1998. 14 Jack A. The French Exception. London: Profile, 2000. 15 Marmor TR, Plowden W. Rhetoric and reality in the intellectual jet stream: the export to Britain from America of questionable ideas. J Health Polit Policy Law 1991;16:807–12. 16 Kudrle RT, Marmor TR. The development of welfare states in North America. In: Flora P, Heidenheimer AJ, eds. The Development of Welfare States in Europe and America. New Brunswick, NJ: Transaction Press, 1990:81–121. 17 Marmor TR. The Politics of Medicare, 2nd ed. Hawthorne, NY: Aldine de Gruyter, 2000. 18 National Forum on Health. Canada Health Action: building on the legacy. Ottawa: National Forum on Health, 1997. 19 Carrasquillo O, Himmelstein DU, Woolhandler S, Bor DH. Trends in health insurance coverage, 1989–1997. Int J Health Serv 1999;29: 467–83. 20 McKeown T. The Role of Medicine: dream, mirage or nemesis? Oxford: Blackwell 1979. 202

VALUES, BELIEFS, AND IMPLICATIONS

21 Illich I. Limits to Medicine, London: Marion Boyars, 1976. 22 Chenet L, Osler M, McKee M, Krasnik A. Changing life expectancy in the 1980s: why was Denmark different from Sweden? J Epidemiol Commun Health 1996;50:404–7. 23 Great Britain Independent Inquiry into Inequalities in Health. Independent Inquiry into Inequalities in Health. London: Stationery Office, 1998. 24 Peckham M. Research and development for the National Health Service. Lancet 1991;338:367–71. 25 The Cochrane Collaboration. http://www.update-software.com/ccweb/ default.html (accessed 7th February 2001). 26 WHO Regional Office for Europe. Targets for Health for All. Copenhagen: WHO, 1985. 27 WHO Regional Office for Europe. Health 21 – health for all in the 21st century. Copenhagen: WHO, 1999. 28 World Health Organization. The World Health Report 2000. Health systems: improving performance. Geneva: WHO, 2000. 29 Saltman RB, Ferroussier-Davis O. The concept of stewardship in health policy. Bull WHO 2000;78:732–9. 30 Murray CJL, Frenk J. A framework for assessing the performance of health systems. Bull WHO 2000;78:717–31. 31 Mooney G, Wiseman V. World Health Report 2000: challenging a world view. J Health Serv Res Policy 2000;5:198–9. 32 Wilde O. The Picture of Dorian Gray. Harmondsworth: Penguin, 1994. 33 Contandriopoulos AP, Lauristin M, Leibovich E. Values, norms, and the reform of healthcare systems. In: Figueras J, Saltman R, Sakallarides C, eds. Critical Challenges for Health Care Reform. Buckingham: Open University Press, 1998. 34 Habermas J. Théorie de l’Agir Communicationnel. Paris: Fayard, 1987. 35 Nozick T. Anarchy, State and Utopia. New York: Basic Books, 1974. 36 Daniels M. Am I My Parents’ Keeper? New York: Oxford University Press, 1988. 37 Rawls J. A Theory of Justice. Oxford: Oxford University Press, 1971. 38 Gillett G. Virtue and truth in clinical science. J Med Philosophy 1995; 20:285–98. 39 Ustun TB, Rehm J, Chatterji S, et al. Multiple-informant ranking of the disabling effects of different health conditions in 14 countries.WHO/NIH Joint Project CAR Study Group. Lancet 1999;354:111–15. 40 Smith AD. Nationalism and Modernism. London: Routledge, 1998. 41 Rousseau J-J. Project Corse. In: Vaughan CE, ed. The Political Writings of Rousseau. Cambridge: Cambridge University Press, 1915. 42 Hobsbawm E, Ranger T, eds. The Invention of Tradition. Cambridge: Cambridge University Press, 1984. 43 Weber M. Essays in Sociology. Gerth H, Mills CW, eds. London: Routledge and Kegan Paul, 1948. 44 Durkheim E. The Elementary Forms of Religious Life (trans Fields KE). London: Free Press, 1995. 45 Smith AD. National Identity. Harmondsworth: Penguin, 1991. 46 Rose R. Lesson Drawing in Public Policy: a guide to learning across time and space. Chatham, NJ: Chatham House Publishers, 1993. 203

HEALTH TARGETS IN EUROPE

47 McNeill W. Polyethnicity and National Unity in World History. Toronto: Toronto University Press, 1984. 48 van Herten LM, van de Water HPA. Health policies on target? Review on health target setting in 18 European countries. Eur J Public Health 2000; 10(suppl):11–16. 49 Rescher N. The Limits of Science. Berkeley, CA: University of California Press, 1984. 50 Popper KR. The Open Society and its Enemies. London: Routledge, 1994. 51 Healthcare Panel. Health Care. London: Office of Science and Technology, 2000. 52 Esping-Andersen G. After the Golden Age? Welfare state dilemmas in a global economy. In: Esping-Andersen G, ed. Welfare States in Transition: national adaptations in global economies. London: Sage, 1996. 53 Mossialos E, Le Grand J, eds. Health Care and Cost Containment in the European Union. Aldershot: Ashgate, 1999. 54 Bartlett W, Roberts JA, Le Grand J. A Revolution in Social Policy Quasimarket Reforms in the 1990s. Bristol: Policy Press, 1998. 55 Saltman R, Figueras J. European Health Care Reform: analysis of current strategies. Copenhagen: WHO, 1997. 56 Smee C. United Kingdom. J Health Polit Policy Law 2000;25:945–51. 57 Poullier J-P, Sandier S. France. J Health Polit Policy Law 2000;25:899–905. 58 Pfaff M, Wassener D. Germany. J Health Polit Policy Law 2000;25:907–14. 59 Bergmark A. Solidarity in Swedish welfare – standing the test of time? Health Care Analysis 2000;8:395–411. 60 European Bank for Reconstruction and Development. Transition Report 1999. London: EBRD, 1999. 61 Appleby J, Boyle S. Blair’s billions: where will he find the money for the NHS? BMJ 2000;320:865–7. 62 Diderichsen F. Sweden. J Health Polit Policy Law 2000;25:931–5. 63 Reichard S. Ideology drives health care reforms in Chile. J Public Health Policy 1996;17:80–98. 64 Harris D. Cases and Materials on the European Convention on Human Rights. London: Butterworths, 1999. 65 Hewson B. Why the Human Rights Act matters to doctors. BMJ 2000; 321:780–1. 66 McKee M, Mossialos E, Belcher P. The impact of European Union law on national health policy. J Eur Social Policy 1996;6:263–86. 67 Kanavos PG, McKee M. Cross-border issues in the provision of health services: are we moving towards a European health policy? J Health Serv Res Policy 2000;5:231–6. 68 European Court of Justice. Case C-158/96, Raymond Kohll v Union des Caisses de Maladie. Luxembourg: ECJ, 28 April 1998. 69 McKee M. An agenda for public health research in Europe. Eur J Public Health 1998;8:3–7. 70 Mossialos E, McKee M. The Amsterdam Treaty and the future of European health policy. J Health Serv Res Policy 1998;3:65–7. 71 Weil O, McKee M. Setting priorities for health in Europe: are we speaking the same language? Eur J Public Health 1998;8:256–8. 204

VALUES, BELIEFS, AND IMPLICATIONS

72 Weil O, McKee M, Brodin M, Oberlé D, eds. Priorities for Public Health Action in the European Union. Luxembourg/ Paris: European Commission/ Société Française de Santé Publique, 1999. 73 McKee M, Garner P, Stott R. International Co-operation and Health. Oxford: Oxford University Press, 2001. 74 McKee M, Mossialos E. Seattle and the World Trade Organization: potential implications for the NHS. J Roy Soc Med 2000;93:109–10. 75 Price D, Pollock AM, Shaoul J. How the World Trade Organization is shaping domestic policies in health care. Lancet 1999;354:1889–92. 76 Levit K, Cowan C, Braden B, Stiller J, Sasenig A, Lazenby H. National health expenditures in 1997: more slow growth. Health Aff Millwood 1998; 17:99–110. 77 WTO Secretariat. Health and Social Services: background note by the Secretariat. S/C/W50, New York: WTO, 1998.

205

14: Perspectives on health governance in the 21st century ILONA KICKBUSCH

Introduction The context for public health has changed considerably over the last 20 years of health policy development. Peter Drucker, whose work provided the initial rationale for “management by objectives” which became so popular in the health policy arena, was also one of the first to speak of “the new realities” 1 with which modern societies are faced: the changing role of governments, changing demands on political leadership, a new pluralism of interests, a new view of political and social responsibility. As documented in the contributions to this volume, European countries are experiencing conflict over the postwar models of solidarity: organisation and financing of social security, welfare, and health care. Globalisation, new regional bodies, international agreements, and increasing global competitiveness influence national decisions. An extensive debate on the role of the nation state and its limitations has ensued.2 Despite significant GNP growth in many countries, increased well-being and overall social health3 have not necessarily followed and inequality gaps persist and have even increased in some countries. Health remains one of the policy arenas most staunchly defended by nation states, yet in a changing economic and political environment the role and positioning of health in politics and society also change. The introduction of health goals and targets has not just been an internal managerial effort but also a response of the health sector to the major restructuring of late modern societies which brings with it new complexities, new risks and new benefits in all spheres of life.4 This contribution is therefore structured around three important dimensions of new forms of governance in times of rapid change: ●

206

the expansion of territory

PERSPECTIVES ON HEALTH GOVERNANCE IN THE 21ST CENTURY ● ●

the ordering of the new territory the new patterns of power sharing that are emerging.

The professional, political, and social dynamics facing the health sector are not unique, they are a reflection of the critical choices likely to face citizens and decision makers in the 21st century. These have been summarised in a recent report of an OECD meeting on “Governance in the 21st century”5 as follows: ● ●

●

old forms of governance are becoming increasingly ineffective new forms of governance will involve a much broader range of active players new forms of leadership are emerging which continuously shift the allocations of power and which weaken centralised/top down decision making structures.

For anyone working in the health arena these three trends in governance are part of everyday experience: health systems are considered ineffective and in crisis, the responsibility for health is diffused at various levels and in different sectors of society, and patterns of leadership in public health continue to need focus and strengthening. But there is a larger governance question to be addressed that moves far beyond health policy. Ulrich Beck,6 in his extensive work on “risk society”, has stated that the central challenge to late modern societies is to answer the question “How do we want to live?”. The debates on health and health policy are part of a society wide process of social learning to find an answer that goes beyond instrumentalism (let’s manage the existing systems better) in search of a new rationale. Giddens7 has used the term “life politics” to encompass a new sphere of polity and governance where the “old” sectoral divisions are ever more difficult to maintain and where the issues at stake move far beyond wealth distribution to the distribution of developmental resources.8 The health debate reflects this clearly: where, for example, does health policy end and social policy begin? How do health quality and social quality of life overlap and reinforce one another? Which part of government is accountable for the persistent inequalities in health? Where do health leadership and stewardship reside? How do we evaluate complex social programmes? What political philosophy and which values drive the health governance debate? In order to reflect adequately on these issues it becomes necessary to relate the health target debate of this book to the broader discourse on governing late modern societies. Indeed, the health debate could contribute significantly more than it has done so far to this discourse; 207

HEALTH TARGETS IN EUROPE

it is after all one of the largest sectors in the late modern state as well as constituting one of the central dimensions of quality of life. Drucker1 maintained that the change we are witnessing from an industrial society to a knowledge based society is as profound as the shift from agrarian to industrial production. Yet the logic of many of the institutions and organisations that structure everyday life and welfare in postmodern societies remains in the industrial/mechanistic/ top down mode. The Industrial Revolution was a revolution of tangibles – railways, machines, and products of the assembly line – which necessitated a specific public health response, which was brought about in Europe through a complex interplay of social movements, social reform, improved living conditions, public health infrastructures, and medical advances.9 The new technology revolution is a revolution of intangibles such as ideas, knowledge, and software and brings with it the need for new forms of public health organisation. In 1985 Lester Breslow, one of the leading US epidemiologists and father of the Alameda County study, argued that “the stage is set for a new public health revolution”.10 Fifteen years later in a JAMA commentary,11 he optimistically stated: “Society seems to be entering a third public health revolution”. Breslow considers that conceptualising health as a “resource for living” and shifting the focus of health promotion strategies to “capacity building for health” is the timely, unique, and revolutionary approach to health for the beginning of the 21st century. In doing so he draws on the document that in his mind has best captured this reorientation: the Ottawa Charter for Health Promotion, adopted by an international meeting of the WHO in 1986.12 Indeed, the subtitle of the Charter is “The move towards a new public health”. Breslow sees the third public health revolution as the necessary and appropriate response to the epidemiological shift in modern societies, especially increased longevity. Given the enormous progress in fighting disease, he states: “It is possible to turn more attention to the nature of health and regard it … as a resource for living”. But all knowledge of social change processes tells us that such a rational argument, while valid, can in no way be sufficient. It needs a wider contextual framework to explain the new intellectual drive for health, the focus on health resources and capacities, the rediscovery of “the social” in health, the increasing interest in the impact of structural factors on health and in the interface between health and social organisation.13 It needs a framework within which these developments can start to “make sense” and can begin to be understood as the expression of a “fit” and 208

PERSPECTIVES ON HEALTH GOVERNANCE IN THE 21ST CENTURY

interface with larger issues of restructuring and governing late modern societies. In order to begin to understand the forces presently driving new approaches to health in the context of the technological revolution, I will draw on two theoretical macro-perspectives. The first has been developed in the work of social scientists such as Ulrich Beck6 and Anthony Giddens7 who see risk as a defining feature of modern societies; indeed, Beck has coined the term “risk society”. While this concept continues to be debated in the social sciences14 and might apply only partially to the challenges faced by so-called transition societies such as Russia,15 it highlights two social processes that are key to the new health governance: the expansion of the magnitude of risk as well as its globalisation and the processes of individualisation that have widened choices and life options but have also led to a loss of social capital and increased delegation of risk management to the individual, the family, and the community. The second perspective has been developed in recent publications on population health and the interface between health and wealth. Keating and Herztman16 have suggested that in late modern societies, health will again play a central role in wealth creation and that nation states – as was the case during the Industrial Revolution – will have to invest significantly in human and social capital in order to remain competitive on a global scale.17 They state: The wealth of nations in the Information Age may depend heavily, perhaps primarily, upon their ability to promote the developmental health of their populations. This, in turn requires them to create the capacity for providing the necessary developmental resources which is a significant challenge during a period of rapid social and technological change we are now experiencing. To achieve this level of persistent social adaptation, it may become advantageous to construct “Learning societies” capable of organising and acting on behalf of human development.

These perspectives help structure the dimensions of a social learning process aimed at creating a new dominant logic for “health” in late modern societies, of which the development of health goals and targets over the last 25 years forms a significant part.

Health targets: redefining and expanding the territory We are still in the midst of a process which seeks new approaches to health governance. From the start health goals and targets were a 209

HEALTH TARGETS IN EUROPE

modernisation strategy which allowed for a new positioning as well as an expansion of “territoriality” for the health sector. The internationally accepted “exemplar”18 for an expansive modern health policy was presented by the Canadian health minister Marc Lalonde in 197419 and was actually couched in the language of place. A New Perspective on the Health of Canadians introduced the health field concept and stated that in order to achieve better population health, five groups of determinants must be addressed: ● ● ● ● ●

biological factors the physical environment the social environment lifestyle factors healthcare services.

In mapping this new territory the policy stated unequivocally that the health sector was responsible not only for the provision of health services and protection of the public’s health; it now laid claim to both “lifestyles” and “living conditions”, expanding its responsibilities far out into the social world and into the realm of individual behaviour. It also contributed to a specific set of expectations that increasingly defined health as one of the “rights” to be delivered by the modern state. This “health imperialism” has been viewed critically by other sectors who saw the “health motive” entering their territory and challenging their own rationales (for example, by suggesting the need for a “health promoting school”), including medicine, which saw a threat to its own dominance in the health arena (doctors are experts on disease, not health). It has also been viewed critically by many social activists and academics who saw an expansion of the control of the state and professionals into the private lives and decisions of people and fear that the normative nature of a healthy life will lead to blaming the victim and to new forms of social control. What followed in the wake of the Lalonde report was a redefinition and repositioning of institutions, epistemic communities, and actors at the “health” end of the disease–health continuum, a perspective that had been developed by Antonovsky20 as a “salutogenic approach”. Health goals and targets have been an important contributing and defining element in this process of expansion. Just as the Lalonde report redefined the role of a modern government in health from a national perspective, so the WHO Health for All strategy redefined the role of the health sector from an international viewpoint. 210

PERSPECTIVES ON HEALTH GOVERNANCE IN THE 21ST CENTURY

In doing so it staked a claim to put health squarely in the centre of development policy, thus expanding its own remit considerably.21 The goal of health policy was defined as providing all people with the opportunity to lead a socially and economically productive life and three key principles (health, equity, and accountability) and two key mechanisms (intersectorality and participation) were identified. Governments were held accountable for the health of their populations, not just for the health services they provided. This proved to be a cornerstone for the ensuing definition of health as a human right and for arguments that governments provide preventive services ranging from family planning to the prevention of HIV/AIDS. Today it is easy to underestimate the intellectual and territorial revolution that was encompassed in Health for All. It qualifies fully for what Spinoza et al.22 call “history making”, which encompasses three subdimensions. ●

●

●

Acts of articulation, defining the situation or making new sense of it (Health for All). Cross-appropriation and bringing new practices into a context that works by other rules (intersectorality and participation). Acts of reconfiguration – to reframe the whole perception of the way of life (health as a resource for development).

This expansion of territoriality and redefinition was taken even further 10 years later in the Ottawa Charter for Health Promotion12 which not only reinforced the Health for All principles but explicitly set out to create “a new public health”, i.e. a whole new sphere of action in the health arena, with a focus on a social concept of health and the interface between people and their environments. Five key action areas were proposed that constitute a social health strategy: ● ● ● ● ●

healthy public policy supportive environments community action personal skills reorientation of the health system.

New practices were proposed for health professionals, their new skills tool kit was to “enable, advocate, and mediate”.What is perhaps most intriguing when reading the wide range of literature now 211

HEALTH TARGETS IN EUROPE

available on health targets and their development – including the contributions by the Verona Initiative, the European Health Policy Centre, and some of the contributions in this volume – is how robust the five key components of the Health for All approach and the five action areas of the Ottawa Charter have turned out to be. This is explained in part as one studies the OECD governance report5 and discovers that many defining characteristics of new governance for the 21st century appear as defining characteristics in the two key WHO documents: ● ● ●

the framing of a public philosophy based on equity a participatory value base an orientation towards a new ecology of collaboration.

For over 20 years the WHO served in a multitude of ways as a virtual space for social learning on new approaches to health governance. The Health for All principles and the Ottawa Charter approaches appear with new language and in new clothes as the “health territory” is defined and redefined by various epistemic communities: for example, in the “investment triangle” of the WHO Verona Initiative which “is about seeing development as a ‘whole system thing’ and balancing economic, social and health development objectives so that they can become mutually supportive”.23 Indeed, the whole initiative sets out to bring together “politicians, civil servants, corporate strategists, health and development professionals” to work together on a common agenda of improving human welfare. This experience could serve as evidence for a constructivist approach to health policy analysis24 showing what a difference an international organisation can make in actively pursuing an environment in which nation states (and more recently other actors) learn.

The new order of things The expansion of territoriality was taken furthest by the WHO Regional Office for Europe which developed a new health policy for Europe in consultation with the then 32 member states, which was adopted by all of them in 1984. It aimed to: ●

212

integrate action on lifestyles, environment, and the healthcare system following the health field model developed by Lalonde in Canada

PERSPECTIVES ON HEALTH GOVERNANCE IN THE 21ST CENTURY ● ●

create an awareness for equity as a major goal for health policy underline the importance not just of reduced risks but of health and quality of life gains (add health to life, add life to years …).

In doing so the WHO European Office gained a raison d’être far beyond implementing individual programmes and projects: it became a prime mover and catalyst for health policy modernisation in its member states. By adding a new dimension of order to the health field it gained legitimacy to monitor and assess the progress of countries towards the common policy goals and was thus able to expand its own realm of action considerably. This first European policy attempted to harness the ever increasing complexity of the health arena by developing 38 health targets as a “new order” around which all action (that of the office, of member states, and all other partners) was structured. A new architecture became part of the new territoriality, a move that led to an ongoing conflict between two schools of thought and epistemic communities that continues to this day. The first school holds that health targets are inherently a political instrument to address and “order” health determinants, thus expanding the political territory of health. The second, that health targets are managerial instruments to order and manage complexity within the health terrain. While the Lalonde report provided the rationale and mapped the territory, it did not provide an approach to the governability of the ever expanding – real or perceived – health risks. This was launched (more or less at the same time as the Lalonde report) in the USA with its health objectives for the nation, the first ever targets for “Healthy People”.25 As the title indicates these were targets set for improving population health – only indirectly did they refer to better health system performance or to larger social goals related to health and well-being. This type of target setting for health was driven by behavioural epidemiology and the understanding of risk factors for major non-communicable diseases: if you can identify and measure a risk factor it seems rational and probable that you can do something about it. If smoking causes lung cancer then you need to keep people from smoking. From its inception target setting was hampered by this marriage of epidemiology and “managerialism” that it has never quite been able to shake off. In the management literature “management by objectives” had made its entry as an organising principle with a drive for better performance, greater efficiency, and better management of resources. The definition of a health target – as put forward by 213

HEALTH TARGETS IN EUROPE

van de Water and van Herten26 – expresses this move: A target is an explicit endpoint of public health or health care expressed in terms of population health or its determinants to be pursued within a given time with systematic monitoring of progress towards achievement.

Setting population health targets (in the consensus view): ●

● ●

●

makes a clear statement that you can plan for health outcomes, not just for health service encourages a debate on priorities and direction moves the public health sector towards a new kind of accountability and assessment promises rational action based on evidence.

Again we must not underestimate the initial breakthrough this meant in a health world that had worked to quite a different set of rules based on input, not outcomes. At the time of its introduction target setting was indeed a revolution in public health. Epidemiology provided a rationale that made health risks calculable and knowable; the targets allowed you to order them. As a result many of the initial targets were linked to rather simple cause and effect models of behaviour modification devoid of context. They became rational and technocratic policy instruments to order, manage, and account for a risk reality defined by professionals. The wish for governability and order overshadowed the drive to establish a new territory and “make history”. Reducing risk and increasing efficiency took centre stage, despite the fact that the literature on targets repeatedly draws attention to different types of health targets (political/inspirational, policy/managerial, and technical/practical). But from the very start the epidemiological-rationalist approach was plagued by two realities: first, that any order is always incomplete and imperfect and in the final analysis there is ordering but no order27 because new risks emerge, and second, that even some of the most straightforward epidemiological risks need a very complex political and social process in order to address them adequately. The WHO, in its role as a catalyst and advisor to countries, did not really insist on the necessary interface between the political and the managerial and was itself pulled in both directions. As a consequence it did not address head on the modern health policy paradox which has been expressed so ably by Kimmo Leppo. 214

PERSPECTIVES ON HEALTH GOVERNANCE IN THE 21ST CENTURY

One of the great paradoxes in the history of health policy is that, despite all the evidence and understanding that has accrued about determinants of health and the means available to tackle them, the national and international policy arenas are filled with something quite different.28

Increasingly target setting became a technocratic/professional/ managerial enterprise rather than a process to set in motion the acceptance of new political priorities for health policy, in order to define and ensure the new health territory. Indeed, recent experiences in England show that while targets at first seem to be an ideal approach to monitor accountability and performance at various levels of the health system, their “overuse” can become counterproductive and unmanageable as time is spent on reporting rather than on implementing policy. The power of definition is crucial in establishing governability; the categories we choose to establish order will drive the process and the solutions. Leonard Syme29 and most recently the US Institute of Medicine report Promoting Health30 called for a new categorisation for health action that is not based on disease categories but takes into account the extensive knowledge of the determinants of health. A partial step in this direction was taken by Michael McGinnis31 in comparing the 10 leading causes of death with the actual causes of death. It was also attempted in the “Lifestyles and Health” targets of the 1984 WHO-Euro target document32 which categorised action areas (policy, environments, skills) and behaviour clusters (positive and negative health behaviours) rather than discrete risk factors. Yet although target setting has become an accepted and ongoing modernisation component of health policy in many OECD countries (an overview presented at a conference in 1999 in Paris identified 27 countries that have generated health targets, next to regions, cities, and communities), there has been surprisingly little attempt until very recently to find a new categorisation and a new order that moves beyond the epidemiological/managerial risk model. An interesting exception are some Canadian provincial health strategies of the 1990s, such as that of British Columbia.33 This policy establishes three principles: ● ● ●

interaction between the individual and the environment shared responsibility for creating health public health and well-being as a fundamental investment that creates healthier societies both in economic and other terms. 215

HEALTH TARGETS IN EUROPE

In using the significant evidence base on health determinants it goes beyond framing its five priority areas in terms of diseases and chooses instead key intervention areas. ● ● ● ● ●

Social adjustment Physical health Public health Mental health Social integration

The policy is driven by the seminal changes in “postmodern” societies: changing family patterns and gender roles, changing nature of work, loss of social cohesion and integration, new forms of social organisation. It then goes one step further. It aims to avoid the verticality that often goes hand in hand with target setting and tries to underline the interdependence of the priority areas. Success in one area will undoubtedly affect the others, a fact that is often neglected in target documents. It does this by identifying six overall strategies, which will support the achievement of all targets and aim to address what I would call the critical pathways. ● ●

● ● ●

●

Encourage the reinforcement of the individual’s potential. Provide support in social settings and develop healthy and safe environments. Improve living conditions. Act for and with groups at risk. Coordinate public policy and action to promote health and wellbeing. Orient the health and social services system towards the most effective and least costly solutions.

This approach does not shy away from addressing the complexity of such health issues as violence, child abuse or rape; it offers explanatory factors for each of the problem areas. The integrated strategies aim to tackle the problems closest to the root causes without being simplistic or unrealistic and with a clear understanding of the social determinants of many of the health problems in modern societies. The priority area of social adjustment, for example, addresses: sexual abuse, neglect and violence against children, behaviour problems among children and teenagers, delinquency, violence against women, homelessness, 216

PERSPECTIVES ON HEALTH GOVERNANCE IN THE 21ST CENTURY

alcoholism, and drug abuse. Practical proposals involving a range of actors in different sectors of society are put forward and clarity is always maintained that the proposed targets measure the symptom, not the determinant. Most importantly, the approach chosen by this strategy takes into account the underlying factors that promote health and those that influence the susceptibility to a whole range of diseases. But a policy such as this was to be the exception. In the course of the 1990s health policy moved increasingly back into its original domain, that of providing health services, and the political debate in most countries was dominated by finance driven issues of healthcare provision, rather than issues of production of health in the broader societal domain. In this cost cutting environment target setting was caught up in small mindedness; indeed, the low point was reached when several authors suggested that a criterion for the selection of targets should be that the health sector could do something about them (see the overview in van de Water and van Herten26). This constituted a final rollback from what had initially been the claim to a new territory. It was a singular retreat not only from new health governance but from long established public health principles most brilliantly expressed by Rose:34 “that the primary determinants of disease are mainly economic and social, therefore its remedies must also be economic and social. Medicine and politics cannot and should not be kept apart”. This political dimension is now re-entering the target arena, most expressed (as described in this volume) in the Swedish equity oriented health strategy35,36 and in the English Saving Lives: our healthier nation37 and the National Health Inequality Targets38 that followed it. Both policy documents come from established welfare states engaged in a major “reinvention” and modernisation process of governance. Indeed, in April 2001 the English Health Secretary launched a “modernisation agency” to lead the NHS into a new era of reform and improvement. These moves show clearly that the formulation of health targets is not a technical-rational exercise based on best evidence but an inherently political process within a specific meaning in a specific context.39 Both health policies are value based and equity oriented, both were only possible with a social democratic/Labour government in power that wanted and allowed for both an expansion of health territory and a “new ordering”. Indeed, the six main categories of the “Green paper on health objectives for Sweden” published by the 217

HEALTH TARGETS IN EUROPE

National Committee for Public Health (a parliamentary committee established in 1997) are in effect a “life politics” agenda: 1. 2. 3. 4. 5. 6.

strengthening social capital growing up in a satisfactory environment improving conditions at work creating a satisfactory physical environment stimulating health promoting life habits developing a satisfactory infrastructure for health issues.

It is expected that the Swedish national health goals will be adopted by Parliament in early 2002; at present they have the support of five of the six political parties in the Swedish Parliament. Each public sector would be accountable for contributing to the achievement of the public health goals based on the premise that the outcome – a healthy society – would provide each respective sector with positive externalities that flow from better health. For this reason the parliamentary committee was given three years to work on the strategy and include a wide range of societal actors in the debate and selection of the targets as a concrete practice of collaborative governance for a better quality of life.

Patterns of power sharing The areas of conflict between the political and the managerial, and between the social and the epidemiological, have been expanded to include a debate about the extent and form of the new governance and about the pattern of power sharing between the state, civil society, and the market. All debates on the new governance in the 21st century are based on the premise that there is an increasing overlap between these spheres; indeed, that while any one sector may dominate the others at one period of time or in one sphere of action, none of these sectors is able to maintain dominance over the others for long. There is an increasing debate about new definitions of social justice, public and private goods, the new social contract between the state and the citizen, and the new responsibilities of the private sector.7 The central governance issues that emerge have of course also manifested themselves in the health arena as a key area of modernisation and life politics: ● ●

218

the changing role of the state the increasing importance of networks as a form of governance

PERSPECTIVES ON HEALTH GOVERNANCE IN THE 21ST CENTURY ●

the growing importance of mechanisms for social learning in order to be continuously in conversation on the common goals.

The strategic state The process of health goals and targets has continuously reinforced the view that improved health is a legitimate goal of government policy and an appropriate role for the state. Twenty years ago this constituted quite a revolution and its general acceptance is proof of the extensive social learning process that has taken place in governance. However, while this responsibility was being established, it also became increasingly clear that the new governance could no longer remain “state centred”. This had been intrinsic to the post second world war welfare state model, but now it became necessary increasingly to involve other actors and to move towards a pattern of power sharing. Reinicke40 has clarified that this involves not only vertical subsidiarity – a model very familiar to most European nation states, many of which have highly decentralised health sectors – but also horizontal subsidiarity, which includes not only what the health debate has called “intersectorality” but also increasing overlaps between the public sector, the private sector, and civil society. Knowledge and power in late modern societies, it is argued, are so widely distributed that cooperation becomes a “new categorical imperative”.41 Societal problem solving is not possible unless all sources of innovation are tapped constantly.What follows is that accountability is not only vertical but also horizontal – in the social arena we are witnessing this as non-governmental groups challenge the healthcare industry on the pricing and availability of drugs. In the health sector it is expressed through the growth of patient groups that challenge the exclusivity of professional expertise while in the policy arena it finds its expression in the development of the tool of environmental, social, economic or, most recently, health “impact assessment”42,43 or in tools such as the “Verona Benchmark” which relates to best practice in partnership building.23 In such a context the state becomes “strategic” and focuses on three tasks: ● ● ●

catalysing the social learning cycle redesigning the organisational architecture rethinking foundational values. 219

HEALTH TARGETS IN EUROPE

In the health arena setting health goals and targets has meanwhile become a clear expression of the “strategic state” and many of the analyses of experiences with target setting stress again and again the importance of “learning about health” inherent in the process of target development. Governance theories also stress the importance of “meso” institutions and mediating structures which allow for the dialogue between all parties to evolve and which serve as centres of social learning, such as the health forums and intersectoral committees that have been created in a multitude of forms.The new roles for health professionals as defined in the Ottawa Charter come to mind: mediate, advocate, enable, as do the health promotion approaches of settings for health. Given the many actors involved in governance it becomes increasingly important to create mechanisms and institutions that bring them together and enable them to develop and accept common goals and direction. Developing targets – at whatever level of governance from international to organisational – provides a “common context of interpretation” and broadens the legitimacy base for critical choices, particularly if the step is taken to expand the territory and include others. Cooperation does not just happen, social capital does not just come about, trust is not just there – it needs to be constantly produced and reproduced and it needs “bridging capital”44 to do so. Such structures allow the constant exploration of models of “how we want to live” and according to which models of solidarity we want to proceed. The network Manuel Castells45 has defined the network as the organising structure of the 21st century. And the health world is increasingly defined by networks at all levels of governance; indeed, the European Union rightly sees network building as one of its key functions in public health. In the early 1980s the WHO-Euro spearheaded this approach and began to work with cities and local authorities, universities, professional organisations, regions, companies, schools, prisons, and hospitals, creating networks of commitment and diffusion that carried the new health policy message to a wide range of collaborators in other sectors, organisations, and all levels of governance. Through myriad meetings, consultations, publications, and other formal and informal mechanisms, it set up a social learning process for the new concept of health territory and order. 220

PERSPECTIVES ON HEALTH GOVERNANCE IN THE 21ST CENTURY

Some of the chapters in this book refer back to the enormous influence the small Copenhagen WHO Regional Office exerted over the health policy debate in Europe and beyond, drawing its strength and credibility precisely from the fact that it was small and catalytic, yet set an ambitious agenda and intellectually and strategically challenged its partners and worked by persuasion rather than control. A new ecology began to emerge which for a period transformed the WHO European Office into the hub of a network of health networks. While the WHO-Euro’s first health targets document in 1984 was clearly centralistic in focus and addressed to national ministries of health (a fact deplored frequently by federal countries such as Germany), experiences with networks such as “Healthy Cities”46 spearheaded a reorientation which is expressed in the new Health 21 document which states: Whether one is a government minister, city mayor, company director, community leader, a parent or individual, Health 21 can help develop action strategies that will result in more democratic, socially responsible and sustainable development. Health is a powerful political platform.47

Even so, much still remains to be done to realise that the network is not just another form of intermediate organisation but that it brings a truly new quality to the governance which needs to find its expression in new governance mechanisms and a new architecture that recognises networks as consensus/inducement oriented organisations and institutions.41 The active citizen The new governance debate stresses the role of the “active citizen” as the corollary to the strategic state. In the health arena this has been viewed critically by those concerned about the expansion of the “medical eye” and an increased control of life choices that are deeply personal.48 A case in point is the Ottawa Charter definition of health promotion “as the process to increase control of people over their health”.This took its lead from the health definitions of the major social movements of the 1970s and 1980s (the women’s health movement, the self-help movement, the gay rights movement, the conciencazion movement of Paolo Freire) yet seems to fit just as well with the ambivalent processes of individualisation in risk societies. In consequence some authors (see, for example, Petersen49) contend that this is not a move towards empowerment but an increased privatisation of risk. 221

HEALTH TARGETS IN EUROPE

Others41 would argue that the new health governance is only possible as a new type of social contract between the “strategic state” and “active citizens” which in turn reflects the understanding of health as a coproduced good within the structure of everyday life. This is clearly expressed in the English Saving Lives: our healthier nation which is presented as a “national contract” and a three way partnership between individuals, communities, and the government, laying out the responsibilities of each partner in the document and under each respective target. This is where the real crux lies. Will there be the political courage to discuss the role of health, the responsibility of the state, the active citizen, and the other societal actors in late modern societies? What amount of resources do we want to invest in health and quality of life? Who should pay? Is 10% of GNP really sufficient in a society where the average life expectancy is nearing 80 years? What kind of health sector do we want? The Swedish health strategy set the explicit goal to integrate public health with general welfare policy; as a consequence it shifts the territory and establishes a new order by framing the targets in terms of social determinants. The next target debate needs to build on this “exemplar” and move beyond the public health architecture of the present system – this is what the third public health revolution will be about.

The future of health governance Health targets need to express the cutting edge of what matters for people in the context of their everyday lives and what matters for society as a whole as it moves through a major historical reorientation. I have argued on several occasions50,51 that “second generation” health targets will need to fulfil quite different criteria from the approach most countries have chosen to date. 21st century health policy must be bold in framing health priorities in a new way by moving into new territory and adopting new categories. Of course, such a reorientation is not possible through rational choice; it is an immensely political undertaking. And it begs the question of whether it can be brought about through an evolutionary process of learning or whether it will need a crisis to catapult policy makers into action. The history of public health, and the epidemiological data of the present, give a clear message: action is needed in and by sectors other than health.Which means the challenge lies in putting a political process and an architecture of governance 222

PERSPECTIVES ON HEALTH GOVERNANCE IN THE 21ST CENTURY

into place that can respond to this policy challenge. Two key issues need to be addressed in the process: first, the value placed on health in comparison to other social goods; and second, the framing of health policy as a common endeavour to improve the quality of life and create a wide range of positive externalities. But can policies be constructed from the question: “What makes people healthy?”. In view of rapid developments in genetics, biomedicine, and healthcare organisation, what sort of health field concept could emerge in the early 21st century? I propose to consider nine principles in order to expand the health territory as a key dimension of life politics, support a new ordering of the health world and its strategies, and move towards new forms of power sharing. 1. The value base and political philosophy of the new health governance needs to be constantly and consistently developed and expressed. In the European political, social, and cultural context this includes a commitment to equity, to solidarity for health, and responsible and accountable stewardship by the state. While in many countries health remains a “defining national characteristic”, the role of European institutions and agencies such as the European Union, the Council of Europe and the WHO Regional Office for Europe must be to create a constant dialogue and a common language on health as a defining characteristic of common European citizenship. 2. The new health governance must focus its policies on addressing the social determinants and social gradients of health, in particular as they relate to the new realities of modernisation and globalisation and the impact of the risk society on population health. The evidence base for a determinants based health policy is sufficient, its application is linked to political will and political process. Indeed, the knowledge on health determinants is becoming increasingly differentiated and gives a range of very concrete pointers for policy action; for example, the research on the influence of early child development on lifelong health, or knowledge of the health impact of working conditions or social capital.52, 53 3. New health policies must address health in its complexity and focus on sustainable gains in health and well-being across the lifespan. They should follow the dictum that a small shift in a large number can bring about significant population health gain. They should address the specific risks and benefits of the late modern risk society as they affect the health and quality of life of populations. 223

HEALTH TARGETS IN EUROPE

Our evidence base is not yet geared towards measuring lifespan health in the context of everyday life and it has led us to underestimate the cumulative/long-term (negative or positive) effect of many small interwoven factors of social organisation and social change. The focus on risk behaviour has also led to the neglect of social, mental, and emotional health factors as well as to the neglect of the health and well-being of children and young people, who seem to be the population group paying the price of modernisation. 4. New health policies are support led policies that set clear investment goals related to different sectors in government and society. They understand health to be a resource and invest systematically in resources and assets for health. Education, labour, and traffic policy, for example, provide crucial support to health. The increasing debate on health impact statements seeks to find ways to measure and include the effects – both positive and negative – of these other policies on health. Costs and resource implications would need to be calculated across sectors given the very high level of positive and negative externalities of all policies. A new health policy also needs to consider the rationale and needs of sectors other than health and hold the health sector accountable for its own contribution to societal well-being. Priority should be given to the building of healthy communities and healthy workplaces, strengthening the wide range of networks for health and increasing individual and community capabilities to lead healthy lives. Supporting social capital and creating social opportunity is a crucial challenge for health and social policy in modern societies. 5. A new commitment to both vertical and horizontal accountability for health will demand increased transparency of all actors in the health arena as well as new forms and channels of information to guide decision making not only within the health sector but across society. New types of public health reports that address wider audiences and speak not only to health experts but to political decision makers and the public at large are already being produced in some countries, regions, and cities. Citizen feedback must be a central component of health accountability. New reporting formats can include a health equity index (as proposed by Milio in 198854 and recently proposed in the UK) or a social stress and modernisation index. In the United States a social health index has tracked developments over the last 30 years 224

PERSPECTIVES ON HEALTH GOVERNANCE IN THE 21ST CENTURY

using 11 indicators. This index shows clearly that during a period of extraordinary economic growth, the social health of the population has actually decreased significantly. Indeed, measures that take account of the interface between public health and social and economic policy are of particular importance. The measurement of externalities has been suggested by a UNDP study on “Global public goods” which would show the effect of externalities between sectors and between national and transnational health effects. 6. A new governance architecture that gives high visibility to health as a resource and is committed to the collaborative imperative is essential. It must explicitly organise collective learning on how to coproduce health as an overall systems goal, not as the output of the health sector. This needs endorsement at the highest political level for the health agenda and a clear organisational base for the health terrain of the “strategic state”, for example through the appointment of a minister for public health. The local, regional, and global dimensions of policy action will gain importance and in many cases the national level will focus on agenda setting, providing norms, frameworks and standards for action and playing a brokering role between different levels and interests. It also needs flexible network based mechanisms that allow for the involvement of a wide group of stakeholders, partnerships, and alliances. This participatory policy process is as important as the evidence, the content, and the direction. New roles will emerge for public health departments and national public health agencies. Indeed, a larger governance issue is the creation of what has been called “a department of consequence” which monitors the positive and negative externalities between sectors as an independent body accountable to the public. 7. The close relationship between health and wealth must be understood and reinforced to create wider societal commitment to reducing health inequalities. This is all the more important because it is becoming increasingly difficult to disentangle the impact of national health goals and targets from other factors operating simultaneously at many levels of governance. Sharing responsibility for the attainment of targets can be fostered through the adoption of a health strategy by Parliament and all government ministers. It can be reinforced through other cross-government mechanisms such as the announced cross-government spending review to be undertaken in England on health inequalities. Goals, targets, and 225

HEALTH TARGETS IN EUROPE

mechanisms must be set out clearly in the process. A Finnish analysis of health targets and its pitfalls for politicians sets this out clearly: “No responsible politician will commit himself or herself to a target set as a percentage reduction of a certain mortality indicator unless the relevance, meaning, means and processes to reach it are understandable and beyond reasonable doubt”. 8. The new health governance implies that health policy and target initiatives can arise at any point in the system and be initiated by any actor. Since much of target setting is “framing”, symbolic politics, and agenda setting, there is no reason to leave the initiative to the government and the strategic state; any group that feels a responsibility for better health governance can and should get involved, as was the case with regions and cities in a number of European member states. Health professionals will increasingly need to be willing to accept leadership from other sectors of governance, in particular from civil society. And as the importance of health grows the health sector will be increasingly faced with the challenge from other sectors to take on the responsibility for the new public health, for example from local authorities, the private sector, and non-governmental organisations. This can only be resolved through collaborative mechanisms, networks, and bridging institutions. 9. The new health governance must integrate international, global, and sustainable development dimensions. Nation states will have to pool their internal sovereignty in the health arena and work through intergovernmental, international, and global mechanisms and alliances. Less and less can we see health policy as policy internal to the state. Many of the health determinants are affected by factors outside the control of nation states and a successful health strategy cannot be insular.55 In Europe it could well be the case that the challenge and the innovation will come from the level of the European Union, in particular from the European Parliament, where the protection of national interests is less of an issue. New energy will arise at the interface of the various governance levels depending on where the highest innovation potential lies. Increasingly issues will be brought to the transnational level in an attempt to establish regimes in such health fields as the global treaty on tobacco. Increasingly other global policies will be scrutinised for their health effects – food policies, genetic engineering, intellectual property, trade in general. It will be necessary that other international organisations 226

PERSPECTIVES ON HEALTH GOVERNANCE IN THE 21ST CENTURY

establish principles similar to the European Union which is committed to considering and monitoring the health effects of all its policies. As always it will need enlightened political leaders to show the way forward at national and international level. Health policies will need to move out of reactive mode into being part of shaping societies of the future.They need to have a global dimension and a sense of global responsibility. It seems absurd to enter the 21st century without making use of our vast knowledge on what creates health and turning it into not only national health policy but also benefits for human beings around the globe.

Acknowledgement I would like to thank Kenneth Muoghalu for his help with this chapter. References 1 Drucker P. The New Realities. New York: HarperCollins, 1996. 2 Reinicke W, Denk F. Critical Choices. The United Nations, networks and the future of global governance. Ottawa: International Development Research Center, 2000. 3 Miringoff M, Miringoff ML. The Social Health of the Nation. Oxford: Oxford University Press. 4 Giddens A. Modernity and Self Identity: self and society in the late modern age. Cambridge: Polity Press, 1991. 5 OECD. Governance in the 21st century. Paris: OECD, 2001. 6 Beck U. Risk Society. Cambridge: Polity Press, 1992. 7 Giddens A, with Pierson C. Conversations with Anthony Giddens. Making sense of modernity. Stanford, CA: Stanford University Press, 1998. 8 Sen A. Development as Freedom. New York: Knopf, 1999. 9 Terris M.The changing relationships of epidemiology and society. J Public Health Policy 1985;6:15–36. 10 Breslow L. A prevention strategy: toward health in the year 2000. Health Med 1985;3(2–3):43–4. 11 Breslow L. From disease prevention to health promotion. JAMA 1999; 281(11):1030–3. 12 WHO. Ottawa Charter for Health Promotion. Geneva: WHO, 1986. 13 Blane D, Brunner E, Wilkinson R, eds. Health and Social Organization. London: Routledge, 1996. 14 Lupton D, ed. Risk and Sociocultural Theory: new directions and perspectives. Cambridge: Cambridge University Press, 1999. 15 Yanitsky ON. Sustainability and risk: the case of Russia. Innovation 2000; 13(3):265–77. 227

HEALTH TARGETS IN EUROPE

16 Keating DP, Hertzman C. Developmental Health and the Wealth of Nations. New York: Guilford Press, 1999. 17 Rosencrance R. The Rise of the Virtual State. New York: Basic Books, 1999. 18 Kuhn T. The Structure of Scientific Revolutions. Chicago: University of Chicago Press, 1970. 19 Lalonde M. A New Perspective on the Health of Canadians. Canada: Government of Canada, 1974. 20 Antonovsky A. Unraveling the Mystery of Health. How People Manage Stress and Stay Well. San Francisco: Jossey Bass, 1987. 21 Kickbusch I. The development of international health policies – accountability intact? Social Sci Med 2000;51:979–89. 22 Spinoza C, Flores F, Dreyfus HL. Disclosing New Worlds. Cambridge: MIT Press, 1997. 23 McMahon L, Harvey S, Zigio E, Arnell G. Using the Investment Triangle – towards process guidelines. Copenhagen: WHO Verona Initiative, 2000. (Accessed on the Verona Initiative website: www.who.dk/Verona 24 Haas P. Policy knowledge and epistemic communities. Forthcoming in the International Encyclopedia of the Social and Behavioral Sciences (26 volume set). New York: Pergamon Press, 2001. 25 US Public Health Service. Healthy People: Surgeon General’s Report on Health Promotion and Disease Prevention. Washington DC: Government Printing Office, 1979. 26 van de Water HPA, van Herten LM. Health Policies on Target? Review of health target and priority setting in 18 European countries. Leiden:TNO, 1998. 27 Burchell G, Gordon C, Miller P, eds. The Foucault Effect: studies in governmentality. Hemel Hempstead: Harvester Wheatsheaf, 1991. 28 Leppo K. Introduction. In: Koivisalu M, Ollila E, eds. Making a Healthy World. London: Zed Books, 1998. 29 Syme SL. To prevent disease: the need for a new approach. In: Blane D, Brunner E, Wilkinson R, eds. Health and Social Organization. London: Routledge, 1996. 30 IOM. Promoting Health: intervention strategies from social and behavioral research. Washington DC: Institute of Medicine, 2000. 31 McGinnis JM, Foege WH. Actual causes of death in the United States. JAMA 1993;270(18):2207–12. 32 WHO. Health for All Targets. Copenhagen: WHO, 1984. 33 OPH. Health Goals for British Columbia: identifying priorities for a healthy population. A draft for discussion. Vancouver, BC: Office of the Provincial Health Officer, 1995. 34 Rose G. The Strategy of Preventive Medicine. Oxford: Oxford University Press, 1992. 35 Agren G. The new Swedish public health policy (2000). (Accessed on the website of the National Public Health Institute Sweden at www.fhi.se (in English)) 36 Oestin P, Diderichsen F. Equity Oriented National Strategy for Public Health in Sweden. A case study. Policy Learning Curve series No 1. Brussels: WHO European Centre for Health Policy, 2000. (Accessed on the ECHP website: www.who.dk/hs/echp) 228

PERSPECTIVES ON HEALTH GOVERNANCE IN THE 21ST CENTURY

37 Hunter DJ, Fulop N, Warner M. From “Health of the Nation” to “Our Healthier Nation”. A case study from England. Policy Learning Curve series No 2. Brussels: WHO European Centre for Health Policy, 2000. (Accessed on the ECHP website: www.who.dk/hs/echp) 38 Department of Health. The National Health Inequality Targets (2001). (Accessed on the Department of Health website: www.doh.gov.uk) 39 Reidpath DD, Allotey P, Kouame A, Cummings RA. Social, Cultural and Economic Contexts and the Measurement of the Burden of Disease. (Report available as pdf file at: www.kcwh.unimelb.edu.au/BOD%20Report.pdf) 40 Reinicke W. Global Public Policy. Governing with government. Washington DC: Brookings Institute Press, 1998. 41 Paquet G. The new governance, subsidiarity and the strategic state. In: OECD. Governance in the 21st Century. Paris: OECD, 2001. 42 Gothenburg Consensus Paper. Health Impact Assessment: main concepts and suggested approach. Brussels: WHO European Centre for Health Policy, 1999. (Accessed on the ECPH website: www.who.dk/hs/echp) 43 Promotion and Education 2001;7(1). Special issue on health impact assessment. 44 Putnam R. Bowling Alone. Princeton, NJ: Princeton University Press, 2000. 45 Castells M. The Rise of the Network Society. Oxford: Blackwell, 1996. 46 Goumans M. Innovations in a Fuzzy Domain. Healthy cities and (health) policy development in the Netherlands and the United Kingdom. Maastricht: University of Maastricht, Department of Health Ethics and Philosophy, 1998. 47 WHO. Health 21 – health for all in the 21st century. Copenhagen: WHO, 1999. 48 Lupton D. The Imperative of Health. London: Sage, 1995. 49 Petersen AR. Risk and the regulated self: the discourse of health promotion as politics of uncertainty. Aust NZ J Sociol 1996;32(1):44–57. 50 Kickbusch I. Setting health objectives: the health promotion challenge. Keynote address at the Healthy People 2000 Health Consortium Meeting, 1996. (http://odphp.osophs.dhhs.gov/pubs/hp2000/consort.htm) 51 Kickbusch I. Target setting – directions for the 21st century. Speech on occasion of 45 years of MSD in the Netherlands. Haarlem:Teyler Museum. 52 Evans RG, Stoddart GL. Producing health, consuming health care. In: Evans RG, et al., eds. Why are Some People Healthy and Others Not? New York: Aldine de Gruyter, 1994:27–64. 53 Marmot MG, Wilkinson R, eds. Social Determinants of Health. Oxford: Oxford University Press, 1999. 54 Milio N. Towards a turn of the century public health. Environments 1988; 19(4):76–88. 55 Kickbusch I, Buse K. Global influences and global responses: international health at the turn of the twenty-first century. In: Merson MH, Black RE, Mills AJ, eds. International Public Health: diseases, programs, systems, and policies. Maryland: Aspen Publishers, 2001.

229

Index

Page numbers in bold type refer to figures; those in italics refer to tables or boxed material. “active citizens” 221–2 advertising, tobacco 26 ageing, of population 18, 19 Alma-Ata Declaration 80 see also “Health for All by the Year 2000” (1997) Amsterdam, Treaty of (1997) 26–7, 169 Anglo-Saxon philosophy 184 autonomous communities, Spain 82–3 behaviour, harmful 37 belief systems 189–92 implications for health policy 192 national differences 192 Beveridge model 21, 89 biomedical model of health 8 Bismarck model 20, 21, 89 blood donations, safety, recommendations 26 breast cancer 36, 42, 43 Canada determinants for better health 210 healthcare coverage 185 health strategies 215–17 cancer 36–7 screening 36–7, 42, 43 case study method 42 comparative 42, 44 cervical cancer 36–7 cholesterol, coronary heart disease risk 35–6 Cochrane Collaboration 187

comparative case studies 42, 44 complexity science 162 confounding variables 44 contracting targets, Sweden 51 cooperation between countries 219, 220 coronary heart disease 35–6 cost containment issues 167, 194, 197 concerns over 195 Germany 92–3 Italy 137–9 Council of Europe 196 impact on health policy 195–200 Countries of Central and Eastern Europe (CCEE) 167, 169, 176 databases Health for All (WHO) 28 National Health Programme (Lithuania) 70 quality of healthcare (Sweden) 64 degenerative diseases, historical phase 19 Dekker case, ruling 197 Denmark 187 diet myocardial infarction risk factor 35, 42 public health guidelines 44–5 unhealthy, in Lithuania 72 England 148–64, 174 Health of the Nation (1992) 148–9, 160 231

INDEX

England continued Health of the Nation (1992) continued communication problems 157 criticisms 152 encouraging partnership 157 evaluation 149 impact assessment 156–7 launch and strategy 151–2 problems with targets 152 review of impact 153 sustaining strategy 157 targets 151, 156–7 health target policy 151–5 health targets achievement 161 deployment and application approach 162 impact assessment 156–7 role 149 target-setting 30 top down 162 undesirable features 161–2 history of health targeting 148–50 Labour Party policies 152–3 Minister for Public Health appointed 153 national inequality targets 157–9 difficulties 159 national service frameworks (NSFs) 155 NHS Plan 149, 154–5 performance indicators 160 responsibility for health issues 150 Saving Lives: our healthier nation (OHN) aims 153–4 key areas 154 target-based approach 160 target-based approach to health policy 159–63 see also National Health Service (UK) Environmental Code (Sweden) 54 environmental legislation, Sweden 54, 58 epidemiological-rationalist approach 214–15 232

epidemiological transition, and phases 19 epidemiology in target setting 6 use in public health 24–5 equity, health 8, 45 definitions 50 Sweden 53 ethical issues 34–5, 37 problems with health targets 35–7 support for health targets 39–40 European Coal and Steel Treaty 25 European Commission 25, 199 action themes (1998) 27 public health action programmes 26 European Convention on Human Rights 196 European Court of Justice, rulings 197 European Health for All Database 25 European health policy 10–11 future prospects 15, 93 historical aspects see Historical perspectives subnational level 14, 15 European Public Health Centre (EPHZ) 104, 111 European Union 25–7, 165 approach to WHO health targets 29–30 closer integration effect 200 dichotomies in approaches 168–70 future prospects for healthcare systems 193 health treatment in other countries 197, 198 impact on health policy 196–200 movement of people 200 political, social and economic development 166–70 public health and health targets role 169–70 public health strategy 199 review of health targets 165–80

INDEX

satisfaction with healthcare system 89–90 states v individuals 181–2 WTO and GATS influence 200 evidence-based medicine 11 “feedback loop,” welfare accounting model 59–60 Finland 117–29, 168, 174 agreement to evaluate HFA 2000 strategy 122 decentralisation of health sector 120, 128 health policy, evaluation of role of targets 123–5 health policy planning/management 119–20 health status 118–19 health targets (1980s–1990s) 120–3 successful programmes 123 health targets (2000) 123–7 evaluation and measurement 127 lay people and politicians’ interpretations 127 list of targets 125–6, 126 policy guidelines 126 HFA 2000 strategy document 121–3 inadequacies and emphasis on policy direction 121–2 revised document 122 municipalities 117, 120 National Public Health Committee, targets 124–5, 126, 127 outcome-related health targets 120–1, 123, 124, 127–8 qualitative targets 123, 128 quantitative targets 123, 124, 127–8 Franco, General F. 77–9 freedom, health as (model) 8–9 General Agreement on Trade in Services (GATS) 200–1 genomics 15

Germany 10, 89–102 cost containment issues 92–3 decentralised health system 91 federal governmental roles/control 91 future prospects 99–101 GVG working group importance and role 97, 99, 100, 115 programme and report 100 healthcare system 90–2, 103 health insurance system 99 Health Ministers’ Conference (1999) 115 health orientation of policies 96 health problems to be prioritised 101 health target implementation 96 at Laender level 91, 96 health targets (1983–1993) 92–5, 103 health survey and target-setting 93–4 lessons learned from 94–5 reports 93, 94 health targets (1997–2000) 95–9 care target selection 97, 98 criteria for selection 97, 98 implementation 96 outcome-related 95–6 weighting of targets 99 health targets at federal level 91, 115 health target-setting 31, 115 priorities 94–5 influence of WHO-Euro’s targets 92 Laender conferences 91 Medical Orientation in the Health System 96–7 national target-setting 31, 89–90, 115 pluralistic health service 94, 96, 103 questions remaining over targets 101–2 social insurance 20 Targets for Health Policy 96 unification problems 94 Zielekorb 100–1 233

INDEX

Germany continued see also North Rhine-Westphalia (NRW) goals, health targets 174–6 governance 11–13 power sharing and 218–22 see also health governance governmental role 38–9 harmonisation, in Europe 170 health coercive 9 concept 34 definition (WHO) 6, 166 development, role of targets in Sweden 50 as duty, or right 13 as freedom (model) 8–9 historical perspectives 18–33 phases 19–20 recent developments 18–20 measuring 6 implicit targets (Sweden) 51 models 8 wealth link 8, 9, 209 Health 21 (WHO) 168, 188, 221 Finland’s response 125–7 goals 5 language used 3, 5 Sweden’s participation 56 values and health governance 13 health action, categorisation 215 health behaviour, monitoring project (Lithuania) 74 healthcare financing 187 “iatrogenesis,” concept 186 organisation 12 quality 64–5 quasi-markets, Italy 140 universal coverage 186–7 healthcare system(s) decentralised Finland 120, 128 Germany 91 Italy 135, 136, 146 Spain 82 development in Spain 79 England 148 234

in Europe and future prospects 193 Germany 90–2, 103 organisation methods 184 pluralistic, in Germany 94, 96, 103 quasi-markets, Italy 140 WHO ranking 90 see also health service health education 45 health expectancy, trends 20 “health flame” 178–9 Health for All (HFA) see “Health for All by the Year 2000” (1997) “Health for All by the Year 2000” (1997) 27–9, 40, 165, 167–8, 188, 212 aims/targets (global) 1, 27–8, 167–8 assumptions over government involvement 168 basis of Lithuanian National Concept of Health 69–70 health targets after 1984 28 influence on Spain’s policies 79–81, 168 North Rhine-Westphalia’s support 104 pioneer work in Spain 77 retrospective review 168–9 WHO Euro’s targets (1984) see WHO-Euro’s 38 targets (1984) “Health for All in the 21st Century” (1998) 28–9 health governance 11–13, 206–29 future prospects 222–7 new approaches needed 209–10 new forms 206–7 power sharing 218–33 trends 207 health imperialism 210 health insurance system, Germany 99 health legislation, Sweden 52–5 health policy development process in Lithuania 69–71 goal 211

INDEX

history/developments see historical perspectives implications of belief systems 191, 192 management cycle, North RhineWestphalia (NRW) 104–5, 106 planning and management (Finland) 119–20 reform evaluation (Sweden) 63–4 state role/competence 14–15 theoretical constructs 14–15 see also individual countries health promotion 44–5, 221–2 health service efficiency improvements 22 integration 176–8 meanings 7–8 national, in UK see National Health Service provision in Sweden 52–3 shift towards planning better health 22–3 see also healthcare system(s) health status Finland 118–19 survey in Germany 93–4 health surveillance, Sweden 62–5 health targets (HTs) 1–2, 2 criteria for adoption and requirements 173 definitions 2, 213–14 evidence against 34–8, 40–1, 43–5, 161–2 failures and reasons 188–9 lack of achievements 40–1 lists and key areas 175, 176 purpose 39 requirements 47 setting see target-setting support for 38–40, 41–3, 46–8, 61 as technical v management tool 30 health territory, expansion 210, 211, 223–7 HFA see “Health for All by the Year 2000” (1997) HFA 2000 strategy document see Finland

historical perspectives (European health policy) 13–16, 18–33, 184 1970s 22 1980s 22–3 after World War II 20–1, 166–7 controlled expansion of healthcare 21, 22 England 148–50 European Union policy 25–7, 166–70 health policy developments 20–3 health target setting 23–5 Lithuanian health policy development 69–71 national/supranational policy 23 prevention policies 21 public health 15–16 scientific developments 21 shift from planning health services to planning health 22–3 Spain 77–9 status of targets in Europe 29–31 Sweden 49 WHO programme 27–9 historical perspectives, on health see health hospitals, historical aspects 7 human rights 13 “imaginisation” 13 implementation of health targets Germany 91, 96 Italy 142–3 North Rhine-Westphalia (NRW) 112–13 “implicit targets” concept, Sweden 62–5 income, distributions 10 Industrial Revolution 20, 21, 208 inequality targets, England 157–9 internal market system 148 intersectoral action 176–8, 178 “intersectorality” 219 Italy 130–1, 130–47, 133, 173–4 adoption of health targets 130 devolution to regions 136, 146 expenditure containment 137–9 235

INDEX

Italy continued future prospects for health targets 145–6 governance system (and definition) 135–7 low horizontal integration of power 135, 137, 143–4 low vertical integration of power 135, 136, 137, 140 healthcare quasi-markets 140 health policy 137–40 influence on HT strategy 143 short-termism 139 health reform legislation (1999) 133–4 managed cooperation 141 Ministry of Health 138 National Health Plan 1998-2000 and HT strategy 130–3, 134 commitment of ministers 143–4 criticisms 144–5 drafting of plan 142, 143, 145 as “exceptional policy” 140–3 implementation, and guidelines 142 origins and Cartona meeting 141 pilot projects 143, 144 regional dimension 144 role as policy instrument 145 subtitle and use of term “pact” 133, 141–2 national health plan draft (2001-2003) 134 national health plan origins 145 national health targets priority areas 130–1, 133 target list 130, 131–2 national identity, concept 191 policy for health targets 130–5 population health approach 146 Servizio Sanitario Nazionale (SSN) 137–8 jurisdiction 190 Kohll case, ruling 197, 198 Lalonde report 210, 212, 213 236

language 3–5 “natural” and “unrestricted” 5 scientific 4–5 used for health targets 2 Las Palmas Declaration 85–6, 85–6 legislation environmental, Sweden 54, 58 European law 196 health, Sweden 52–5 health reforms (Italy) 133–4 life expectancy 10, 18 Finland 118, 119 Sweden 49, 222 “life politics” agenda 218 linguistics 4 Lithuania 10, 69–75 demography 69 health policy development process 69–71, 70 health situation analysis 71–2 monitoring/evaluation of health policy 73–4 mortality rates 71–2, 74 National Concept of Health 69–70 National Health Programme 70, 72–3 purposes 72 targets and strategic actions 72–3 objectives for health improvement 72 public health status 71–2 local health targets 47 Maastricht, Treaty of (1992) 25–6, 165 mammography 36, 43 management by objectives 23–4, 32, 39, 167, 206, 213 application 24 “managerialism” 6 market-based healthcare 194 market socialism 15 “medical police” 13–14 mercantilism 13, 15 mission statements 5 monitoring (of) health policy, Lithuania 73–4

INDEX

health target programme, North Rhine-Westphalia (NRW) 113 morbidity, mortality evolution (debate) 19–20 mortality Finland 118 morbidity, evolution (debate) 19–20 rates in Lithuania 71–2, 74 reduction health target in England 151 target in Lithuania 72–3 myocardial infarction 35, 42 National Health Programme, Lithuania see Lithuania national health reports 31 National Health Service (UK) 148 establishment 21 modernisation 217 national inequalities targets and 158 NHS Plan 149, 154–5 quality of care decline 195 role, agenda and resource allocation 150 National Health Service, in Spain 81–2 national health strategy implementation in England 42–3 local targets v 47 national health targets, Sweden 53 national identity, concept 191, 192 national service frameworks (NSFs), England 155 Netherlands, treatment abroad for patients 198 networks, role in governance 220–1 NHS Plan 149, 154–5 North Rhine-Westphalia (NRW) 103–16, 174 definition of targets (target structure) 111 future prospects and planning 114–15 health policy management cycle 104–5, 106 health target establishment 96

health targets and target areas 110–11 evaluation and monitoring 113 joint targets and benefits 112, 114 prerequisites 114 priorities and problems 115 programmes (addiction/cancer) 112, 113 results (provisional) 113–14 subtargets 111, 112, 113 implementation of targets 112–13 local health conferences 107–8 outcome-related health targets 95–6 public health science faculty 104 Public Health Service Act 108 quantification of targets 111–12 State Health Conference (1991) 104, 105–7, 108, 112 membership 106 topics and resolutions 107 State Health Conference (1993) 108 State Health Conference (1994) 108–9 State Health Conference (1995) 109 target-setting development 103–4 Ten Priority Health Targets for NRW 109–10 objectives, management by 23–4, 32, 39, 167, 206, 213 Ottawa Charter for Health Promotion 208, 211, 212, 221 outcome-related health targets Finland 120–1, 123, 124, 127–8 Germany 95–6 Sweden 50, 57, 58 pandemics, historical phase 19 “pestilence and famine” phase 19 politics 217 health link 13 health targeting as expression of 10, 217 science and 10–11 237

INDEX

politics continued territory expansion and 223–7 positivist model of health 8 poverty 40–1, 44 power sharing, patterns 218–33 privatisation, in Sweden 65 procurement process, in Sweden 65 public health action programmes, in EU 26 autonomous communities in Spain 82 commonality of goals/obligations 61–2 effective targets 12 European Union strategy 199 guidelines and health promotion 44–5 historical aspects in Europe 13–16 revolution 208 status in Lithuania 71–2 Sweden see Sweden Public Health Strategy and Action Programme (2001-6) 169–70 qualitative targets 6, 30 Finland 123, 128 quality, healthcare , indicators (Sweden) 64–5 quality assurance 21 quality of care, decline 195 quantitative targets 6, 30 Finland 123, 124, 127–8 North Rhine-Westphalia (NRW) 111–12 randomised controlled trials (RCT), evidence for/against HTs 36, 42, 44 “reform evaluation,” health policy (Sweden) 63–4 resource allocation 190 risk factors/risk markers 35 “risk society” 209 road traffic safety, target/strategy in Sweden 60–2 science, politics and 10–11 scientific language 4–5 238

Scottish health plan 150 screening, cancer 36–7, 42, 43 short-termism 139, 172 Single European Act 196 smoking 24, 26, 35 social cohesion 178–9, 183 social democracy 15 social development 170 social inequality 40, 45 reduction, as target 46 social insurance 20, 183, 187 social medicine 14 social policy, European diversity 184 social programming, cohesive 178–9 social security 20–1 sociodemography, Finland 118 socioeconomic developments 18 Spain 76–88, 174 attempted coup 81 autonomous communities 82 Catalonian government’s health targets 83 decentralised healthcare system 82 democracy development 80, 81 healthcare system development after 1953 79 health targets 82–4 Las Palmas Declaration 85–6, 85–6 historical aspects 77–9, 81 National Health Service development 81–2 political changes in 1970s 76 primary care development after 1984 80–1 rural primary care centres 77 social policy 81–2 Valencian community 83 WHO HFA strategy influence 79–81, 168 Spanish Public Health Association (SESPAS) 84–5 2000 Report 85 Las Palmas Declaration 85–6, 85–6 specificity, of terms 175 stakeholder perspectives 170–4

INDEX

long-term/short-term 172 perceptual pathways 171, 171 standard of living 12 states, v individuals 181–2 stewardship 188 failures and reasons 188–9 strategies for targets/target-setting 42–3, 47 for achieving targets 41 Sweden 51–2 supranational health policy 14, 23 Sweden 49–68, 174, 195, 222 benefits of targets 49–50 Commission on National Targets 56–8 environmental legislation 54, 58 future prospects 66–7 governmental roles 52–5 healthcare targets 50 health development, targets 50 Health for All strategy progress 55–6 health outcomes and determinants (targets) 50, 57, 58 health policy reform evaluation 63–4 health service provision 52–3 health surveillance and “implicit target-setting” 62–5 historical aspects 49 Institute of Public Health 53 involvement in WHO-Euro 49, 55, 168 legislation affecting targets 52–5 National Committee for Public Health 218 national perspective/targets 50, 53, 56–8 National Public Health Commission 53, 56–8 political aspects of targets 51–2 privatisation and procurement process 65–6 public health 53 improvements 66 national targets 57, 58 reports 62–3 regional targets/target-setting 58–60

road traffic safety case 60–2 Royal Commission proposals 49 strategies for health targets 51–2 target-setting (central level) 52–5 “welfare accounting” model 59–60 Swedish Environmental Code 1998 54 Swedish Health Act 1982 53 target-setting 5, 30, 214 cost containment and 217 developments, historical 23–5 government objectives 46 “implicit targets” (Sweden) 62–5 key areas/targets 176 management by objectives see management by objectives as national not international process 90 optimising of subject identification 175, 175 priorities in European countries 30, 31 see also specific countries as process for development 177 strategies for setting see strategies for targets/target-setting tactics 174–6 technocratic/professional/manageri al exercise 215 “territoriality,” expansion 210, 211, 223 “Third Way” concept 184 tobacco advertising/control 26 top-down approach 14–15 England 162 target-setting failure in Germany 94 Treaty of Amsterdam (1997) 26–7, 169 Treaty of Maastricht (1992) 25–6, 165 Treaty of Rome 196 21 Targets for the 21st Century 29 types of health targets 47 UK health policy divergence 149–50 239

INDEX

UK continued as most centralised state in Europe 150 political devolution 149–50 see also England USA, healthcare coverage 185 values 189–92 explanation/principles 189–90 Verona Initiative 212 virtual reorganisation, interectoral working 177–8, 178 Vision Zero 61 waiting times, as quality indicator (Sweden) 64 wealth, health link 8, 9, 209 “welfare accounting” model, Sweden 59–60 welfare state crises and pressures 193–5 development 183 expenditure concerns 194 extension 184 future prospects 182–6 idealism 166 WHO-Euro Healthy Cities Project 84, 221 WHO-Euro’s 38 targets (1984) 1, 28, 187–8, 212–13 endorsement by member states 81 Spain 82, 83 Finnish strategy document 121–3 health network and 221 influence on Germany 92 influence on Spain’s policies 80 policy content and impact on Sweden 55, 56

240

role in policy planning in Sweden 66–7 Spain’s absence of health strategy 76, 84 Sweden’s participation 49, 55–6, 168 use by North Rhine-Westphalia 109 use by Spanish Public Health Association 84–5 World Bank 169 World Health Organization (WHO) 22, 165, 212 2000 World Health Report 188 criticisms 189 database in Europe 28 definition of health 6, 166 European Office 28, 29 Finland’s agreement to evaluate HFA 2000 strategy 122 health targets 1–2, 28 21 Targets for the 21st Century 29 historical aspects 27–9 see also “Health for All by the Year 2000” key influences on health 1 levels of action, use by North Rhine-Westphalia (NRW) 110–11 Regional Office for Europe 28, 66, 212–13 health targets see WHO-Euro’s 38 targets (1984) World Trade Organisation (WTO) 200, 201