Johan Mackenbach

 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

 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

 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

 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

 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

 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

Policy areaIndicatorNetherlandsEurope TobaccoTobacco Control Scale46 Daily smokers32 Lung cancer mortality6862 AlcoholAlcohol Control index1614 Alcohol consumption1012 Liver cirrhosis mortality626 NutritionIodine deficiency3135 Fat consumption3733 Fruit and vegetables PregnancyTeenage pregnancy Neonatal mortality Maternal mortality ChildMeasles immunization9795 Child Safety Score4636 Postneonatal mortality Mackenbach & McKee 2013

Policy areaIndicatorNetherlandsEurope InfectionsAIDS incidence1.5 MRSA infections Influenza vaccination6153 HypertensionBlood pressure Cerebrovascular mort.3477 Cancer screeningBreast cancer screening2n.a. Cervical ca. mortality Road safetySafety belt use9481 Car occupant mortality Pedestrian mortality Air pollutionSO 2 emissions Urban ozone Summary score% high minus % low565 Mackenbach & McKee 2013

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

 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

Mackenbach & McKee 2013

Mannen Overledenen (abs.) Oversterfte t.o.v. Zweden (abs.) Oversterfte t.o.v. Zweden (%) Longkanker Levercirrose55700 Ischemische hartziekte Zuigelingensterfte Maternale sterften.v.t. Externe oorzaken (1-19)2300 Infectieziekten Cerebrovasculaire aandoeningen Baarmoederhalskankern.v.t. Borstkankern.v.t. Verkeersongevallen Mackenbach & McKee, submitted for publication

Vrouwen Overledenen (abs.) Oversterfte t.o.v. Zweden (abs.) Oversterfte t.o.v. Zweden (%) Longkanker Levercirrose31400 Isch. hartziekte Zuigelingensterfte Maternale sterfte400 Externe oorzaken (1-19)121 Infectieziekten26600 Cerebrovasculaire aandoeningen Baarmoederhalskanker20500 Borstkanker Verkeersongevallen Mackenbach & McKee, submitted for publication

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

Nether -lands

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

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< : p<.001 Mackenbach & McKee 2013

AchtergrondvariabeleJaarNederlandEuropa Bruto Nationaal Product Zelfexpressie waarden2000/ Democratie Effectiviteit van bestuur Linkse partijen in de regering Etnische versplintering Mackenbach & McKee 2013

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

Univariate beta=1.671 (n.s.), multivariate beta = (n.s.)

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

Mackenbach & McKee, submitted for publication

 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

THANK YOU!