Many countries are currently facing a challenge in terms

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1 Health polces on target? Revew on health target settng n 18 European countres LOES M. VAN HERTEN, HARRY P.A. VAN DE WATER * Background: In 1984 the European regon of the World Health organsaton (WHO) adopted 38 targets wthn the framework of the 'Health for All by the Year 2000' strategy. Wth the presentaton of a renewed Health for All strategy n September 1998, t was consdered an approprate moment to revew the use made of health targets n varous European countres. Ths may be helpful n provokng new nterest n the health target approach. Methods: A snowball approach was used n each country to gather relevant polcy documents, reports and other publcatons on health polcy. In addton, experts' opnons were collected by maled questonnares. Draft revews of target settng n health polcy were formulated for each country and were sent to the approprate Mnstry of Health for revew before publcaton. Results: The Health for All strategy has nfluenced the health polcy of almost all countres ncluded n ths study. Most countres have formulated some health targets, whereas other countres have formulated some general prortes, goals or objectves as a related but less specfc approach. Although many countres have formally adopted the health targets set by the WHO, the degree of elaboraton, the focus of the health targets and the practcal mplementatons vary consderably between the countres nvestgated. Concluson: Many countres have formally adopted health targets. Health targets, as a tool n health polcy, are mostly used at a poltcal level and,ther practcal use seems to be n ts nfancy and can be consdered as 'the promsng begnnng of a development'. Keywords: European countres, evaluaton study, Health for All strategy, health polcy, health targets Many countres are currently facng a challenge n terms of natonal health and health polcy and, for ths reason, the exchange of experence and nsght ganed n dfferent countres would be useful. The 1984 Health for All strategy presented by the European offce of the World Health Organzaton (WHO) ncluded 38 targets and was a stmulus to European member states to thnk about settng smlar prortes and ways of achevng health targets. 1 The drect contrbuton of health targets to the mprovement of the health status of a populaton s hard to measure and cannot be dstngushed from the effects of other socetal processes. However, despte the drawbacks on health target settng, there are clear arguments whch ndcate that target settng helps to develop a more ratonal and transparent health polcy. 2 Generally, target settng s a step-by-step process wth ncreasng specfcty (fgure I). It starts wth prncples and values whch may be markedly nfluenced by poltcal opnon. Equty n health and equal access to health care facltes are two examples mentoned n the Health for All strategy. A goal s a very general descrpton based on the prncples and values of what should be acheved n the long term, for example a longer and healther lfe for * L.M. van Herten 1, H.P.A. van de Water 2 1 TNO Preventon and Health, Leden, The Netherlands 2 Formerly: TNO Preventon and Health, Leden, The Netherlands; presently: HELTEF, Nordbyhagen, Norway Correspondence: Loes M. van Herten, M.Sc, TNO Preventon and Health, PO Box 2215, 2301 CE Leden, The Netherlands, tel , fax the nhabtants of a country. In the nternatonal lterature and n many natonal polcy documents t s frequently used nterchangeably wth the term objectve, although, accordng to Unted Natons usage, an objectve s rather more specfc than a goal and s an am whch can be partly acheved durng the plannng perod. Objectves therefore represent a more concrete elaboraton of how the goal should be attaned, such as a reducton n cancer morbdty and mortalty. The subsequent qualtatve targets are more specfc than the objectves and have a concrete deadlne, for example a reducton n smokng n the next decade. In the next step quanttatve targets are set to montor progress. When adequately defned, there s a bult-n evaluaton mechansm wth measurable ndcators. Ths process of formulatng health targets usually stmulates the development of health polcy at natonal, regonal or local level. 3 ' 4 In September 1998 the European member states of the WHO adopted a renewed Health for All strategy, called 21 Targets for the 21 st Century.^ Ths s perhaps an approprate tme to revew the lterature on the use of health targets n 18 European countres n order to determne whether target settng s used as a tool for establshng health polcy and whether the 1984 Health for All strategy was mplemented and ndeed used to set health targets. Ths study may also be helpful n provokng new nterest n the health target approach. Detaled results of ths study are descrbed n our report Health Polces on Target?.^

2 EUROPEAN JOURNAL OF PUBLIC HEALTH VOL NO. 4 SUPPLEMENT Prncples and values I Goals Objectves Qualtatve targets Quanttatve targets Indcators for montorng progress Fgure 1 Increasng specfcty when developng health targets METHODS We nvestgated health target settng n Austra, the Czech Republc, Denmark, Fnland, France, Germany, Hungary, Ireland, Italy, The Netherlands, Norway, Poland, Portugal, Romana, Span, Sweden, Swtzerland and the UK. Data were collected up untl July 1998, by means of computer searches of the lterature and by sendng a questonnare to respondents n all countres. The man nformaton sources used were polcy documents. Because these documents often have a restrcted dstrbuton (the so-called 'grey lterature'), much materal had to be collected by communcatng wth experts n each country. A snowball approach was used. We contacted Mnstres of Health (both the health polcy secton and the documentaton centre), other natonal health nsttutes, embasses, scentsts and other health polcy experts to explan the purposes of the project and to ask for relevant (government and nongovernment) polcy documents, reports and other publcatons. We also sent experts a short questonnare to determne ther opnon about developments n ther country. The questonnare covered the followng ssues. Is health target settng an ssue of debate n your country?. What has been the nfluence of WHO's Health for All ntatve? What s the concrete use of health target settng, the status of development and what are the man actors? Are there related developments n health montorng or nformaton systems? On the bass of the nformaton gathered, we prepared an overvew for most of the countres. For some countres collaboratng nsttutes were asked to prepare the overvews. In the Czech Republc, Hungary, Poland and Romana publc health researchers provded the overvews of the stuaton n ther own country. For Italy, Portugal and Span a senor publc health nvestgator n Span prepared all three overvews. Two Fnnsh researchers prepared the overvew for Fnland. All collaboratng nsttutes receved smlar nstructons on requred structure and format, questons to be addressed, etc. We then used the eght country overvews together wth the documents obtaned and nformaton from the questonnares of the remanng ten countres to prepare a draft revew for each country. These draft revews were sent to the Mnstry of Health n each country for correcton. The feedback we receved gave us the mpresson that our approach for collectng relevant lterature and addtonal nformaton from experts had succeeded. RESULTS The man results of our study are summarsed n table I. Here we hghlght three ssues for each country: the nfluence of the WHO's Health for All strategy on the acceptance of the health targets dea at a natonal level, Table 1 Summary of the country revews on the use of health targets untl July 1998 Country Austra Czech Republc Denmark Fnland France Germany Hungary Ireland Italy The Netherlands Norway Poland Portugal Romana Span Sweden Swtzerland UK Inspred by the WHO Intally yes a Intally yes a, late Intally yes, late Use of health targets Informaton system Exstng system Exstng system Expanson planned Exstng system Exstng system Expanson planned Expanson planned Expanson planned a: The Health for All strategy confrmed exstng prncples b: 'Expanson planned' may vary from beng aware of nadequaces n the system to concrete plans for mprovement

3 SUPPLEMENT Health polces on target? u the practcal use of health targets at a natonal level (n terms of goals, objectves and qualtatve or quanttatve targets) and the support provded by exstng health nformaton systems for a health target approach. Austra Developments had been strongly nfluenced by the WHO Health for All strategy. Current Austran health polcy 6 ncludes a number of targets for both health care and the health nsurance system (concernng qualty and accessblty), as well as several qualtatve targets for health protecton and promoton. Health data used to develop the polcy were obtaned from exstng nformaton systems. Czech Republc The need to restructure the health care system ntally overshadowed nvolvement n the Health for All strategy. Health targets have not been formulated, but the country has a Natonal Programme of Health 7 wth prortes. Ths programme has made use of exstng health data systems, but new forms of data collecton (health ntervew survey) are ^currently beng developed. Denmark The prncples of the Health for All strategy were already mportant before the WHO presented ts strategy. Formally speakng, there s no health target polcy under ths name, but prortes are formulated n the natonal Health Promoton Programme.^ The country s developng a more comprehensve health nformaton system to montor developments n populaton health. Fnland The prncples and values of the WHO Health for All strategy were already accepted before the WHO presented ts report n Although the country was ntally qute actve n developng a natonal health polcy, 9 an economc setback dampened enthusasm for ths approach and prompted dscusson of the ratonng of health servces. 10 The country already has an extensve health nformaton system. France The WHO Health for All strategy has had a clear nfluence n France. The 1994 document Health n France 11 lad the bass for recent health target-settng efforts, both at the natonal and regonal levels and resulted n the organsaton of a Natonal Health Conference to establsh prortes. There has been some expanson of the exstng health nformaton system,.e. annual natonal health reports. Germany After ntal nterest n the Health for All strategy, dscusson on the settng of health targets faded, followed by a later revval. 12 Now, some regons already have or are n the process of formulatng health targets. The health nsurance sector appears to be nterested n applyng health targets as tools for qualty assurance. Some Lander and the federal government are movng to develop better health montorng systems. Hungary The debate on prortes n health polcy began after the WHO Health for All ntatve. A recent law, whch adopted practcally all of the man ponts of the strategy, lsts prortes n health polcy wth the accent on health care. Qualtatve and quanttatve targets for populaton health have been set for the year 2010 and plot projects for practcal mplementaton have been started. 1-5 The health nformaton system wll be modfed to meet the new requrements. Ireland Influenced by the WHO Health for All strategy, Ireland has revsed ts key values for health polcy and has started to reorent ts health servces towards preventon and health promoton. The present health strategy 14 ncludes several health targets at the natonal level, whch are to be worked out at the regonal level by the recently nstalled regonal health boards. Some ntatves have been taken to mprove the exstng health nformaton structure. Italy Although the health target dea was not ntally used, the recently publshed Natonal Health Care Plan 15 ncludes fve natonal targets whch are smlar to those of the Health for All strategy. The focus s on the health care system rather than on populaton health. Health data used to develop the polcy were obtaned from exstng nformaton systems. The Netherlands The Health for All strategy has been an mportant stmulus for the development of current natonal health polcy. Although the settng of quanttatve health targets was rejected n 1992 by the Secretary of State for Health, the most recent polcy sets three general goals. 16 Montorng of populaton health has been extended and mproved through the ntroducton of 4 yearly health reports. Norway Although the Health for All strategy was well receved, there s no clear relatonshp between the strategy and current polcy documents. The report on populaton health 17 ncludes concrete health targets, but the practcal relevance of these targets s unclear. The data used to develop the polcy came from exstng databases on health and health care. Poland Snce 1990 there has been a Natonal Health Programme, whch s clearly based on the WHO Health for All strategy. The 1996 verson of the programme ^formulates 18 strategc goals. Polcy realsaton, wth emphass on

4 EUROPEAN JOURNAL OF PUBLIC HEALTH VOL NO. 4 SUPPLEMENT health promoton, s n an early phase. Improved regulatons for health data systems have been ssued and t s recognsed that there s a need for a more extensve natonal health montorng system. Portugal Gven the smlartes n the formulaton of prncples t s clear that the WHO Health for All strategy had some nfluence. The country's natonal polcy has objectves and the acceptance of health targets les between contemplaton and development. Polcy documents are based on nformaton obtaned from exstng data Romana The Health for All strategy has not strongly nfluenced the country's health polcy, but mportant targets (such as equty, communcable dseases and women's health) have been adopted, leadng to more emphass on health promoton. The health target approach s just startng to be developed. The exstng health montorng and health data collecton systems need to be mproved. Span The Health for All prncples were accepted. Snce 1989, nearly all regons have approved regonal health plans wth approxmately the same set of health targets, although practcal approaches may dffer. 1 A specal health data collecton system was establshed to montor progress n achevng the WHO health targets. Sweden Swedsh polcy documents frequently refer to the Health for All strategy. '^ Health promoton and dsease preventon are prorty areas assocated wth a number of natonal and regonal targets. The country's extensve health nformaton system has been mproved to facltate comparsons between regons. Swtzerland The European Health for All strategy has had a farly strong nfluence on health polcy n ths country. ^ There s no natonal health target strategy, because the federal government does not have the authorty to adopt such a strategy. Swtzerland has reorgansed and mproved ts health nformaton system to adapt to the Health for All programme. UK The ntatve of the WHO nfluenced health polcy n all parts of the UK. England has mplemented the most concrete follow-up to the Health for All strategy. The 1998 strategy Our Healther Naton^ and ts predecessor Health of the Naton^ present a lmted number of quanttatve health targets for England whch affect the practcal organsaton and fnancng of publc health and health care. A specal central unt at the Department of Health has been set up to montor progress towards meetng health targets. These summares show that the health polcy of almost all countres ncluded n ths study has been nspred by the Health for All by the Year 2000 strategy. Most countres have formulated some health targets and, although other countres may not have set health targets, they have all formulated some general prortes, goals or objectves as a related but less specfc approach. In the countres whch have formally adopted health targets, the degree of elaboraton, the focus of the health targets and the practcal mplementaton of these targets vary consderably. The core health targets n most countres are smlar (equty, health promoton, etc.), but there s great varaton n the number of health targets and n ther focus on publc health or health care and n the actors nvolved. The practcal use of health target settng as a tool n Europe seems to be n ts nfancy. It can be consdered as 'the promsng begnnng of a development'. Approprate health nformaton and health montorng systems are a prerequste for settng health targets. Almost all countres have mproved ther health nformaton systems or are n the process of dong so and, consequently, wll be able to respond to the health montorng requrements of the health target approach. DISCUSSION When usng prmary and secondary sources, as we dd, one must be aware of potental confounders. For example, statements about the mportance of startng ponts for a country's health polcy often depend largely upon whch polcy documents are ncluded n the study. Whereas one document focuses on publc health, another from the same perod may emphasse health care. Documents may also express the desrable rather than the actual stuaton. The dfferent extent of regonalsaton n the countres may also cause confuson. Most countres have nattonal health targets, whle some have both natonal and regonal health targets and others have only regonal targets. Such dspartes reflect the dfferent forms of government n European countres. In a federal state such as Swtzerland, the natonal government s not empowered to defne natonal health targets. Despte these lmtatons, the fact that 'grey lterature' polcy documents made up the majorty of the publcatons and the fact that reports on practcal experence were scarce leads us to beleve that, on the bass of our own fndngs, the nformaton gven by the experts and the feedback from the Mnstres of Health, our conclusons reflect the current stuaton n practce. Another pont of dscusson s the defnton of goals, objectves and targets. The terms used n the polcy documents vared between countres. The step-by-step approach for settng the health targets shown n fgure I was seldom adopted n the countres studed. Sometmes the wordng of what was called a target was so general that, accordng to the herarchy of levels n the development of health targets, t should be classfed as an objectve or. goal. As a rule, health targets were formulated n a qualtatve sense and the practcal elaboraton at all levels - as, for example, n England - was the excepton.

5 SUPPLEMENT Health polces on target? The relatvely small number of quanttatve targets probably Steps n development reflects the fact that most countres consder Step 1 health targets a source of nspraton rather than a Step 2 Goals management or techncal tool. Ths nspratona1 Step 3 Objectves Step 4 Step 5 Step 6 Prncples and values Qualtatve targets Quanttatve targets Indcators Coverage ndcated by the shaded areas: aspect s also reflected by the observaton that many targets focus on rather broad areas such as equty, qualty of lfe and health promoton. In some countres health targets were seen as techncal tools for makng polcy decsons n order to acheve an optmal balance between effect (health gan) and allocaton of avalable resources, for example the health nsurance targets n Germany. In other countres, for example Span, health targets are promoted as a management tool. These varous ways of applyng health targets are clearly complementary and compatble. We consder that the use of health targets as a source of nspraton corresponds to the development and applcaton of such targets at a poltcal level, ncludng the artculaton of ntentons and desred drectons. Inspraton mples a focus on steps 1-3 n the target development process shown n fgure 2. In ths process, the polcy level (the use of health targets as a manageral tool) s defned as the producton of a concrete plan for realsaton of the ntentons and desred drectons. Thus, the polcy level ncludes developmental steps 2 (goals) to 4 (qualtatve health targets) but could also cover quanttatve target formulaton (step 5) and the selecton of ndcators for montorng progress (step 6). Use of health targets as a techncal tool s assumed to correspond to the practcal level and suggests concrete mplementaton of plans formulated at the polcy level. Ths use of health targets ncludes developmental steps 4-6, and possbly step 3.^ Ths s, of course, an oversmplfcaton. In practce, the formulaton of health targets follows a cyclcal course wth ncreasng concreteness and ths made t dffcult to place the countres n the cells of fgure 2. Even so, the dagram may help poltcans, polcy makers, professonals and others, whether they work from a macro, meso or mcro orentaton or at the European, natonal, regonal or local level, to understand the ntended use of health targets and to assess how far ther development has proceeded. CONCLUSION We conclude that, n most of the countres studed, health polcy has been nspred by the Health, for All by the Year 2000 strategy, but ths does not mean that these countres have fully developed health targets n ther health polcy. Most countres use health targets as a poltcal tool and only a few countres, such as the UK and Span, have Inspratonal use (poltcal level) oblgatory, Manageral use (polcy level) optonal step Fgure 2 Three uses of health targets n dfferent stages of development Techncal use (practce level) elaborated the health target approach beyond the polcy to the practcal level. In most other European countres, the dea of health targets has ganed poltcal support, whch s an mportant condton for further development. Despte ths poltcal support, health targets need to be developed at the polcy and the practcal levels. We also found renewed nterest n ths tool, whch wll certanly be renforced by the new Health for All strategy of the WHO n Europe. It seems an approprate moment to stmulate dscusson and the exchange of practcal experence. One should realse that the process - whch started n the 1980s - takes tme. An Italan proverb 'Ch va pano va sano, Ch va sano va lontano' ('Who goes slowly goes steadly, who goes steadly goes far') would seem to apply to the practcal applcaton of the health target approach, whch appears to be on the rght track and makng steady progress. Ths study was supported by an unrestrcted educatonal grant from Merck & Co., Inc., New Jersey, USA. We are grateful to all the people who gave us the nformaton whch made t possble to carry out our study. We partcularly want to thank our colleagues from the collaboratng agences for ther help n preparng the overvews for ther countres: Dr R. Gspert Margaroles (Italy, Portugal and Span), Dr V. Kocandrle (Czech Republc), Ms T. Mkkola and Dr M. Shto (Fnland), Professor S. Nagyluskay (Hungary), Ms B. Nedzwedzka (Poland), Dr D. Farcasanu and Dr L. Marnescu (Romana). We would also thank the referees of ths artcle for ther helpful comments. 1 World Health Organsaton Regonal Offce for Europe. Targets for health for all: targets n support of the European strategy for health for all. Copenhagen: WHO Regonal Offce for Europe, Van Herten LM, Gunnng Schepers U. Revew: targets as a tool n health polcy. Part I: lessons learned. Accepted for publcaton by Health Polcy. 3 Rtsataks A. Settng targets for health: defntons and experences n Europe. Handout for partcpants at the workshop 'Health Targets, Health Care and Health Polcy n the European Unon'. Hannover, aprl Brussels: WHO Regonal Offce for Europe, 1999.

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