1. Johan Mackenbach

2.  Europe is an underutilized ‘natural laboratory’ for policy evaluation  Over the past 40 years, there were enormous variations in population health trends  While health care and social policies have often been studied, health policy has not

3.  Successes and failures of health policy in Europe: performance indicators  The Netherlands: strengths and weaknesses of health policy  Determinants of health policy performance: economic, social, political

4.  Tobacco control  Alcohol control  Food and nutrition  Fertility, pregnancy, childbirth  Child health  Infectious disease  Hypertension  Cancer screening  Mental health  Road traffic injury  Air pollution Mackenbach & McKee 2013

5.  Tobacco control  Alcohol control  Food and nutrition  Fertility, pregnancy, childbirth  Child health  Infectious disease  Hypertension  Cancer screening  Mental health  Road traffic injury  Air pollution Mackenbach & McKee 2013

6.  Tobacco control  Alcohol control  Food and nutrition  Fertility, pregnancy, childbirth  Child health  Infectious disease  Hypertension  Cancer screening  Mental health  Road traffic injury  Air pollution Mackenbach & McKee 2013

7.  Literature reviews to identify effective interventions  Relate implementation to intermediate and final health outcomes  Select performance indicators and create summary score  Rank countries, identify determinants of health policy performance Mackenbach & McKee 2013

13. Policy areaIndicatorNetherlandsEurope TobaccoTobacco Control Scale46 Daily smokers32 Lung cancer mortality6862 AlcoholAlcohol Control index1614 Alcohol consumption1012 Liver cirrhosis mortality626 NutritionIodine deficiency3135 Fat consumption3733 Fruit and vegetables239217 PregnancyTeenage pregnancy1.45.4 Neonatal mortality2.93.9 Maternal mortality4.711.0 ChildMeasles immunization9795 Child Safety Score4636 Postneonatal mortality1.02.1 Mackenbach & McKee 2013

14. Policy areaIndicatorNetherlandsEurope InfectionsAIDS incidence1.5 MRSA infections2.64.4 Influenza vaccination6153 HypertensionBlood pressure131133 Cerebrovascular mort.3477 Cancer screeningBreast cancer screening2n.a. Cervical ca. mortality2.45.8 Road safetySafety belt use9481 Car occupant mortality0.52.8 Pedestrian mortality0.11.5 Air pollutionSO 2 emissions2.313.4 Urban ozone13603584 Summary score% high minus % low565 Mackenbach & McKee 2013

15. HEALTH POLICY PERFORMANCE IN 43 EUROPEAN COUNTRIES, 2008 Mackenbach & McKee 2013

16.  Enormous gaps in implementation of effective health policies in Europe, particularly in Central and Eastern Europe  Substantial part of gap in life expectancy with Western Europe is due to higher mortality from causes of death amenable to health policy  Even in Western Europe, countries could typically reduce years of life lost by 30-50% by adopting policies in countries with best practices

17. Mackenbach & McKee 2013

18. Mannen Overledenen (abs.) Oversterfte t.o.v. Zweden (abs.) Oversterfte t.o.v. Zweden (%) Longkanker6709370955 Levercirrose55700 Ischemische hartziekte600400 Zuigelingensterfte37812333 Maternale sterften.v.t. Externe oorzaken (1-19)2300 Infectieziekten408205 Cerebrovasculaire aandoeningen346200 Baarmoederhalskankern.v.t. Borstkankern.v.t. Verkeersongevallen50812525 Mackenbach & McKee, submitted for publication

19. Vrouwen Overledenen (abs.) Oversterfte t.o.v. Zweden (abs.) Oversterfte t.o.v. Zweden (%) Longkanker371400 Levercirrose31400 Isch. hartziekte437800 Zuigelingensterfte31710232 Maternale sterfte400 Externe oorzaken (1-19)121 Infectieziekten26600 Cerebrovasculaire aandoeningen537700 Baarmoederhalskanker20500 Borstkanker321394830 Verkeersongevallen2026331 Mackenbach & McKee, submitted for publication

20. Will: Political commitment Business support Professional engagement Population support Means: Knowledge and information Institutional arrangements Organizational effectiveness Financial resources Delivery: Initiation or redesign Population coverage Programmatic design Monitoring and evaluation Background: Economic conditions Political conditions Social conditions Mackenbach & McKee 2013

22. Nether -lands

23. Traditional values emphasize: God is very important Obedience and religious faith more important than independence Abortion never justified Strong sense of national pride Respect for authority Survival values emphasize: Economic & physical security more important than self-expression and quality of life Would not sign a petition Have to be careful about trusting people

24. GDPValuesDemocracyGovt. eff. Tobacco control score++ Alcohol policy score++ Neonatal mortality+++ Child safety score++ Influenza vaccination+++ Cervical cancer mortality--- Seat belt wearing++ SO 2 emissions--- Summary score+++ +: p<.05 ++: p<.01 +++: p<.001 Mackenbach & McKee 2013

25. AchtergrondvariabeleJaarNederlandEuropa Bruto Nationaal Product20003192718227 Zelfexpressie waarden2000/061.940.11 Democratie2000107.73 Effectiviteit van bestuur20022.090.79 Linkse partijen in de regering1990-200931.8637.66 Etnische versplintering20010.110.29 Mackenbach & McKee 2013

26.  Political science literature: social-democratic government reduces income inequality  No association between social-democratic government 1990-2008 and health policy  Weak association between social-democratic government 1960-2008 and health policy Mackenbach & McKee, submitted for publication

27. Univariate beta=1.671 (n.s.), multivariate beta = -0.103 (n.s.)

28. Mackenbach & McKee, submitted for publication Univariate beta=1.381 (p=0.04), multivariate beta = 0.812 (n.s.)

29. Mackenbach & McKee, submitted for publication

30.  Over the past decades, there have been large differences between European countries in the implementation of effective health policies  Seen from a European perspective, the Netherlands is part of a “sub-top”, with excellent performance in some areas and modest performance in some others  Tobacco control and alcohol control are among the areas in which the Netherlands can do better – but this will require more political will

31. THANK YOU!