Understanding the process of establishing a food and nutrition policy : the case of Slovenia

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This is the published version of a paper published in Health Policy.

Citation for the original published paper (version of record):

Kugelberg, S., Jönsson, K., Yngve, A. (2012)

Understanding the process of establishing a food and nutrition policy: the case of Slovenia.

Health Policy, 107(1): 91-97

http://dx.doi.org/10.1016/j.healthpol.2012.06.005

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N.B. When citing this work, cite the original published paper.

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Health

Policy

jo u r n al h om ep a ge :w ww . e l s e v i e r . c o m / l o c a t e / h e a l t h p o l

Understanding

the

process

of

establishing

a

food

and

nutrition

policy:

the

case

of

Slovenia

Susanna

Kugelberg

_,

_Kristina

_Jönsson

_,

_Agneta

_Yngve

a_{UnitforPublicHealthNutrition,DepartmentofBiosciencesandNutrition,KarolinskaInstitutet,14157Huddinge,Sweden} b_{DepartmentofHealth,NutritionandManagement,OsloandAkershusUniversityCollegeofAppliedSciences,Oslo,Norway} c_{DepartmentofPoliticalScience,LundUniversity,Lund,Sweden}

a

r

t

i

c

l

e

i

n

f

o

Received28January2012

Receivedinrevisedform12June2012 Accepted13June2012

Keywords:

Publichealthnutrition Agenda-setting Foodandnutritionpolicy Policyentrepreneur Role

Functions

a

b

s

t

r

a

c

t

Background:TherehasbeenanincreasingeffortacrossEuropetodevelopnationalpolicies infoodandnutritionduringthelastdecade.However,littleisknownabouthowpublic healthnutritionissuesgetonthepublichealthagendaandtherolesindividualshavewhen theseagendasarebeingset.

Objectives:Theaimsofthisstudyweretoscrutinisethedevelopmentprocessofthe Slove-niannationalfoodandnutritionpolicy,andtoidentifytherolesandfunctionsofindividuals whohavecontributedtothatprocess.

Methods:Thisstudyundertookaqualitativeapproach.Datacollectionincluded18 semi-structuredinterviewsbetween2007and2011,andgreyandscientificliteraturesearch.Text analysiswasbasedonKingdon’sstreamsmodel,whichinvolvedhighlightingthe relation-shipbetweenproblemidentification,policysolutionsandpoliticalopportunities.Datawere codedtoidentifytherolesandfunctionsofindividualsparticipatingintheagenda-setting process.

Results:TheanalysisshowedthattheopportunityfortheSlovenianfoodandnutrition pol-icytobedevelopedwaslargelyexplainedbyachangeinpoliticalcircumstances,namely theaccessionofSloveniatotheEuropeanUnionandtheCommonAgriculturalPolicy. Indi-vidualswithexperienceinpolicydevelopmentwereidentifiedbecauseoftheiranalytical, strategicandpolicyentrepreneurialskills.Theanalystwasresponsibleforcommunicating thekeynutritionissuestopolicy-makers,thestrategistjoinedinternationalnetworksand promotedpolicysolutionsfrominternationalexpertsincludingtheWorldHealth Organi-zation,andthepolicyentrepreneurtookadvantageofthepoliticalsituationtoenlistthe participationofpreviousopponentstoanationalnutritionpolicy.

Conclusion:Thisstudyfoundthatindividuals,theirrolesandskills,playedanimportant roleinthedevelopmentoftheSlovenianNationalFoodandNutritionPolicy.Theroles andfunctionsoftheseindividuals,whichareidentifiedinthisstudy,mayassistfuture endeavourstoadvancepublichealthnutritionasakeypoliticalissue.

© 2012 Elsevier Ireland Ltd. All rights reserved.

∗ Correspondingauthorat:UnitforPublicHealthNutrition, Depart-mentofBiosciencesandNutrition,KarolinskaInstitutet,14157Huddinge, Sweden.Tel.:+46852481164;fax:+4652481174.

E-mailaddress:susanna.kugelberg@ki.se(S.Kugelberg).

1. Introduction

There has been increasing political interest in and

developmentofnationalactionplansrelatedtofoodand

nutritioninEuropeduringthelasttwodecades[1].

How-ever, the literature on what instigates nutrition policy

developmentandtheprocessofdevelopinganationalfood

0168-8510/$–seefrontmatter © 2012 Elsevier Ireland Ltd. All rights reserved.

92 S.Kugelbergetal./HealthPolicy107 (2012) 91–97

andnutritionpolicyislimited[2–4].Whilsthistoricaland

politicalliteratureoffersanunderstandingofhowpolitical

institutions,powerandconflictinfluencepolicy

develop-mentandpertinentpoliticalissues,thereislittleevidence

aboutthefactorsthatfacilitaterapidpolicychange,

partic-ularlyinregardstohealthissuessuchasnutrition[2,3,5].

TheadoptionoftheSlovenianNationalFoodand

Nutri-tionpolicy(FNAP) in2005 marksanimportant turning

pointforhealthinthiscountryhowever,thereislittle

pub-lishedaboutthisevent.SomeobserversoftheSlovenian

scenesuggestthehealthstatesecretarynotedthemarked

differencesin standardized mortalityrates betweenthe

eastandwestregionsofSlovenia[6–8]andwasadequate

toinstigatepolicychange.Othercommentatorsstatethat

theaccession totheEuropeanUnion(EU)andCommon

AgriculturalPolicy(CAP)providedanopportunityfor

gov-ernmenttointegratehealthandagriculturalpolicy-making

[9].Itisdifficulttodeterminefromtheliteraturethe

spe-cificreasonstheSlovenianhadforadoptingtheFNAPand

whyithappenedatthatparticulartime.Thisstudy

there-foreaimstoreconstructtheprocessthatledtotheadoption

oftheSloveniannationalfoodandnutritionactionplanin

2005andtoidentifytherolesandfunctionsofkeyactors.

Reviewingtheprocessunderlyingthedevelopmentofthe

SlovenianNationalfoodandNutritionpolicycanhelpto

providevaluable insights forthose pursuing todevelop

foodandnutritionpoliciesbutwhofaceimportantpolitical

challenges.

ThisstudybuildsontheJobNutproject,whichwas

con-ductedduring2006–2008.TheobjectiveofJobNutwasto

assesscurrent and futurelabour marketissues relevant

tothedevelopmentofaneffectiveandefficientEUpublic

healthnutritionworkforce[10].Theprojectwasfundedby

theEuropeanCommission,DirectorateGeneralEducation

andCulture,asaLeonardoproject.

1.1. Thestreamsmodel

Inordertoreconstructthedevelopmentofthe

Slove-nian National Food and Nutrition Plan we needed to

understand the roles and skills of the key actors and

theinteractionbetweentheseindividuals.The “streams

model”byJohnW.Kingdon’sisamodelusedtoexplore

rapidpolicychangeandtheroleofindividualsinthat

pro-cess[11].InKingdon’smodel,attentionisfocusedonthe

couplingofthree streams:theproblem stream,the

pol-icysolutionstream,and thepoliticalopportunity stream.

Thecouplingofthesestreamscanbetriggeredbyanew

politicaladministrationormajorpoliticaleventsthat

pro-videopeningsforanewissueorpolicytobeintroduced

andincludedontheagenda.AccordingtoKingdon,these

policy‘windows’ are scarceand have a short duration.

However,whenwindowsareopen, thelikelihoodofan

itemmakingtheagendaisincreasedwhenaskilled

pol-icyentrepreneurispresent.Policyentrepreneurscanbe

foundin numerousplacesincludingwithingovernment

agencies,non-governmentorganisations(NGOs),orexpert

communities.Theseindividualsarewillingtoinvesttheir

resources(time,reputation,and/orknowledge)ina

partic-ularproposalforpolicychange.Theyalsoneedtomanage

timingskilfully,or asKingdonnotes,“hooksolutions to

problems, proposals to political momentum and

politi-cal events to policyproblems” (p. 182 [11]). Kingdon’s

modelwasanappropriatetechniquetoguideouranalyses

becauseithighlightstheimportanceofskilledindividuals

ininfluencingsudden,unexpectedpolicychange.

2. Methodsandmaterials

Thisstudyutilizedaqualitativeapproachtoreconstruct

thepolicydevelopmentprocessoftheSloveniaactionplan

infoodandnutritionin2005.

2.1. Studyparticipants

A total of 18 respondents completed interviews.

No invited study participant declinedparticipation (see

Table1).Themostimportantcriteriafortheparticipantsin

thisstudywere:havingdirectinvolvementinthe

policy-makingprocess oftheSloveniannationalactionplan in

foodandnutritionin2005and/orhavinggeneral

knowl-edgeofpublichealthnutrition(PHN)policydevelopment.

Theprimarysampleofrespondentsincludedthosewith

experienceintheSlovenianPHNpolicy-makingprocess.

The secondary sample consisted of PHN practitioners,

expertsandpolicy-makersfromFinlandandSweden;this

groupand wasincludedtoidentifymore generally,key

rolesandfunctionsinPHNpolicy-making.

2.2. Datacollection

Data werecollectedintheformofinterviews,

scien-tific articles and governmental reports during the time

period2007–2011.Theinterviewsweresemi-structured

andconductedbythefirstauthorusinganinterviewguide

thatwasinformedbythepolicyliterature.Semi-structured

interviewswerechosenbecauseit provideda

standard-ized template for questioningbut retainedsome ofthe

flexibility of in-depth interviews [12]. The interviewer

invited participantstoshare theirexperiencesbasedon

theirprofessionaland/orexpertrole.Theinterviewslasted

for40min–1handwereconductedinEnglish.All

inter-viewsweretaperecordedandtranscribed.Oneinterview

wasconductedinthepresenceofaninterpreter,because

therespondentdidnotspeakfluentEnglish.

The scientific literature was identified searching in

PubMed, using Slovenia and policy and public health as

searchterms.Fromthe67papersretrieved,13paperswere

identifiedasbeingrelevantfromtheirtitle.Paperswere

excluded if the abstractfocused on clinical health care

reformsorclinicalnutrition.Thefinalselectionincluded

7 papersthat provided informationregarding (a)Public

healthnutritionproblemidentification,(b)Publichealth

nutritionstructuresandactorsand(c)foodandnutrition

policy-makingcontext.

During the analysisstage 20 additional papers were

included becausethey covered important topics, which

Table1

Datacollection.

Institution/organisation Respondents Scientificandgreyliterature

Slovenia Sweden Finland

CivilservantinMinistryofHealth/Social welfare/Agriculture

2 1 1 Publichealthnutritionproblem

identificationn=5[6–8,16,17]

Expertinnationalagencyrelatedtopublic healthnutrition

1 5 3 Publichealthstructuresandactorsn=4

[9,13–15]

PHNpractitionerinregionalpublic healthinstitute

2 Thecontextoffoodandnutrition policy-makingn=5[22,25,29,32,33]

PHNpractitionerfromCINDI(CountryIntegrated Non-CommunicableDiseasesInterventionProgramme)

2 Intergovernmentalfoodandnutrition policyn=9[18,19,21,23,24,26–28,30]

Researcherinacademia 1 KeySlovenianGovernmentalpolicieson

foodandnutritionn=4[20,31,34,36]

Total 18 27

Table2

Keyrolesandfunctionsintheagenda-settingprocess.

Roleandfunctions

Problemidentification

Analyticalrole

Toconductsurveysbasedon

epidemiologicalprinciplestohighlightthe problem

Tocommunicatethenutritionissueby repeatedlygivinginformationto policy-makers

Policysolution

Strategicrole

Tostrategicallysearchforpolicysolutions abroad

Tojoininternationalexpertnetworksin foodandnutrition

Topromotepolicysolutionsfrom internationalexpertorganisations

Politicalopportunity

Policyentrepreneurialrole

Totakeadvantageofpoliticalchange Tothinkbeyondthenutritionissue Toenlisttheparticipationandsupportof opponentstocreateawin-winsolution Tomergeinterestsandknowledgetoa commonpolicy

2.3. Dataanalysis

Weusedcontentanalysistoassessallcollectedmaterial. WeusedthethreethemesfromKingdon’sstreamsmodel tocategorisethecollectedmaterialnamely,identification oftheproblem,policysolutionsandpoliticalopportunity. Eachofthesethemeswasusedtocodekeyactor’srolesand functions,asshowninTable2.Assessmentofthegreyand

scientificliteraturewasusedtosupportandbuildupthe

narrativearoundthesefindings.Tovalidatethefindings,

weofferedallinterviewrespondentstheopportunityto

readandcommentonthispaperbeforepublication.The

JobNutprojectreceivedethicalapprovalfromtheRegional

EthicalReviewBoardinStockholm,Sweden.

3. Results

Theresultsarepresentedaccordingtothethreestreams

model themes problem identification, policy solution

and political opportunity. The findings are drawn from

documentsidentifiedthroughthegreyandscientific

lit-eraturesearch,anddatafrominterviewedrespondents.

3.1. Problemidentification

Traditionally, public health topics in Slovenia were

debated withina social medicine paradigm.The

social-medicineperspectivedatesbacktothe1920s,whereactors

suchasAndreijaStampar(1888–1958)andorganisations

suchastheLeagueoftheNationsandRockefeller

foun-dationinfluencedthecontentsofhealthpolicies[13].In

1985,whenSloveniawasstillpartoftheformerrepublic

ofYugoslavia,debatesontheroleofpublichealthleadto

thedevelopmentofthepresentstructure,withthenational

publichealthinstitute(PHI)andnineregionalPHI[14].

In1991,SloveniagainedindependencefromYugoslavia

andimportantchangesinthelifestyle ofthepopulation

emergedasaconsequenceofthechangingpoliticaland

socioeconomiccontext [15].During this time resultsof

epidemiologicalresearchshowedthattheburdenof

non-communicablediseasewasincreasingacrossthecountry,

with extreme morbidity apparent in the north-eastern

regions,forexamplePomurje[16].

Initially,thisgrowingproblemofchronicdiseasewas

the concern of only a small group of medical

aca-demics,doctorsandepidemiologistsinthePHIsandhealth

professionals active in the World Health Organisation

(WHO) initiated CountryIntegrated Non-Communicable

DiseasesInterventionProgramme(CINDI)[6].Theseactors

raisedawarenessofimportantPHNissuesincluding

obe-sity,nutritioninequalities,schoolnutritionschemesand

breast-feeding.Byorganisingeventstoshowtheresults

ofepidemiological studiesandcommunicatingnutrition

issues todifferent audiences,these actorssucceeded in

highlightingtheseverityofthesePHNissues.The

publi-cationofthefirstnationaldietaryintakesurveyin1997

byVerenaKoch(aPhD Student)[17],provideddatafor

keyactorstohighlightthediscrepancybetweentheWHO

CINDIFoodBasedDietaryGuidelineswiththeSlovenian

situation. The diet of the nation became a politically

chargedissueandleadtotheNationalInstituteofHealth

Insurance,organisedbytheMinistryofHealth,namingthe

94 S.Kugelbergetal./HealthPolicy107 (2012) 91–97

Epidemiological monitoring of health behaviours as

an important tool for policy change and raising the

awarenessofhealthproblemswiththemediaand

politi-cianswashighlightedbyarespondentfromFinland:

“Iwanttocomebacktothemonitoring,Ithink itis

reallyimportant,nottomonitorthediseases,butthe

riskfactorsandthebehaviours,becauseifyouhavea

goodsystem,whichmonitorshowsmokingis

develop-ing,howbloodpressureisdeveloping,bloodcholesterol

levels,itisreallyimportant,itgivesfeedbacktothe

peo-ple,itgivesfeedbacktothepolitician.Wealwayssay,

whatismeasuredgetstalkedabout.”

3.2. Policysolution

In 1992,following the Ministerial World Conference

inRome,theWorldDeclarationonNutritionandPlanof

Actionwaspublished[19]andtheWHObegan

encourag-ingmemberstatestodevelopnationalfoodandnutrition

policies.Asaresult,thePHIinSolevniaprepareda

back-grounddocumentforthedevelopmentofthefirstNational

HealthPlan(NHP)“HealthforallbytheYearof2000”[20].

In1993,theMinistryofHealthpresentedthisdocumentto

theparliament.Itemphasizedtheimportanceofabalanced

diet,healthpolicies,healthylifestylesandreducinghealth

inequalities.ItwasclearlyinfluencedbytheWHO’s“Global

StrategyforHealthforallbytheyear2000”[21].ThisNHP

however,wassignificantlydelayedduringthe

parliamen-taryprocess.Onerespondentexplainedthissituation:

“Itwasinteresting thatthis documentwasproposed

totheSloveneParliamentin1993andittookitseven

yearstopasstheprocedure.Thepartiesunfortunately

discussingthenationalhealthplanmuchlongerthan

expected.”

AsmallSlovenenetworkofacademics,CINDImembers,

andindividuals fromthe PHIquestionedtheway these

issueswerebeingadministratedbyparliamentandjoined

alargerinternationalPHNnetworktosearchfornewpolicy

solutions.Asonerespondentsaid:

“Ididsometraining,internationalcourses,whichwas

developedbyWHO.Iwantedtoincreasemyknowledge

inhowtodevelophealthlifestylesindifferentsettings.

Irememberonecoursethinkitwasin97,whichwere

crucialformywork.”

TheWHOregional officefor Europewasa keyactor

inthisnetwork.Nutritionpolicieshadbeenheavily

pro-motedbyElisabethHelsing,regionaladvisorfornutrition

duringtheyears1984–1996[22].In1992,Aileen

Robert-sonjoinedtheofficeandbecameresponsibleforadvising

thecountrieswithintheEuropeanRegiononpublichealth

andnationalnutritionpolicy.Shebecametheleadingactor

in theendorsement of theWHO EuropeanRegion First

Action Plan for Food and Nutrition Policy (2000–2005)

[23–25].Throughworkshopsandseminars,memberstates

wereprovidedwithcomprehensivematerials,guidelines

andtoolstoassistwithpolicydevelopment[26,27].

Joz-icaMaucecZakotnik,thedirectorforCINDISloveniawas

invitedbytheWHOtojointheseworkshops[28].TheWHO

meetingsand workshopsprovided forumswhereactors

sharedandsupportedeachothertopursuenutritiongoals

andobjectivesintheirnationalsetting.

Asonerespondentputit:

“In1998,itwassomeconferenceandAileenRobertson

tookover,sheisreallysomethingspecial.Shestartedto

workonthefirstfoodandnutritionplanfortheWHO

Europeanregion.ThiswasthepushforSloveniatostart,

andJozicaMaucecZakotnikjoinedaswell.”

RespondentsfromSwedenhighlightedthatministerial

meetingsarrangedbytheWHOasimportantvenuesfor

networkingandencouragingpolicychange.One

respon-dentfromSwedenalsoacknowledgedWHOanimportant

sourceforpolicydevelopment:

“If we speak about healthy diets, then I think one

major actor is the WHO. We attended a WHO

con-ference, and other scientific officers from the other

ministerswerethere...andtheWHOreallystressesthat

everymember state needto have a national

leader-ship and that we need todo somethingto promote

healthy diets...During theseconferences, peopleare

reallyinfluencingeachother...”

In parallel to the developments within the WHO

regionalofficeforEurope,theEUaddedpublichealthas

anareaforpolicyactionintheAmsterdamTreatyof1997.

The EuropeanCommission alsoset up anexpert group

withintheEURODIETproject,inordertoidentifythemain

nutritionissuesfortheEUin1999[29].DuringtheFrench

presidencyoftheEuropeanCouncilin2000,PHNgained

furthermomentumwithintheEUandresultedina

Reso-lutiononHealthandNutritionfromtheEuropeanCouncil

[30].

Inthelate1990skeySloveneactorstriedtotranslate

internationaldevelopmentstotheSloveniancontextand

intheframeoftheCINDIprogramme.Asoneputit:

“So, in 1998 we started several developments of

nutrition policies, in the frameof our regular CINDI

programme, together with different partners, also

involvingministriesresponsiblefoodandnutrition,also

professionalsindifferentfields.Thisalsoinvolved

peo-plefromWHO.”

3.3. Politicalopportunity

Theyearof2001wascharacterizedbyswiftchanges

withintheSlovenian governmentandopeneddoors for

newideas.In2000theNHP[31]waspassedandin2001a

nationalsurveyofunhealthybehaviourwasinitiatedand

completed[6].Thenewgovernmentappointedinautumn

2000 appointed the CINDI director as a state secretary

specificallyforpublichealth.Duringhertermasstate

sec-retaryofpublichealth,thepreparationfor FNAPbegan.

As oneleading actor atthat time explained:“We

actu-allystartedtoputthegovernmentagainstthewall, and

involvedalltheministries,triedtomakethemtoseetheir

owngoals,andconvincingthemthatthiswassomething

Respondents in Finland and Sweden also stressed

theimportanceof leadershipin enablingpolicychange.

Leadershipwasdescribedassomeonethatwasexercising

influenceandauthoritytogetthesupportofopponentsto

createawin-winsolution.

The Ministry of Agriculture, Food and Forestry was

proventobethemostdifficulttoengageinthe

develop-mentoftheSlovenianFNAP.Theirfocuswasagriculture

and primary production namely dairy farming, animal

stock and corn, barley, and wheat crops. A window of

opportunityarosein2001withtheaccessiontotheEU

andtheobligationsforSlovenianlawtoharmonizewith

EU legislation, specificallythe commonagriculture

pol-icy(CAP).TheCAPprovidesvariousagriculturalsubsidies,

which have thepotentialtoimpactona wide range of

domesticpolicies.Inparticular,CAPwasbelievedtohavea

substantialinfluenceonthenationalagriculturalandfood

productionsystemandpublichealth[9,32–34].The

indi-vidualresponsibleforadvisingcountrieswithintheWHO

EuropeanRegiononpublichealthandnationalnutrition

policy,AileenRobertson,gotinvolvedintheSlovenianfood

and nutritionplandevelopmentand proposedtotakea

healthimpactassessmentoftheCAP.Thehealthimpact

assessmentoftheCAPwasbelievedtobeadriverforthe

MinistryofAgriculture,FoodandForestrytosupportthe

foodandnutritionplanandcreatedanopportunityfor

mul-tisectoralcollaboration.TheMinistryofAgriculture,Food

andForestryrecognisedthatahealthimpactassessment

ofCAPcouldbeinstrumentaltotheirownfoodpolicygoal,

orasonerespondentexplained:

“TheMinistryofAgriculture,FoodandForestrywasalso

notsatisfiedwiththeCAP,becausetheSlovene

Agricul-turestrategyfrom1993wasmuchmoremodernthan

CAPatthetimeoftheaccessionofSloveniatoEU.

Agri-culturesectorusedsomeofthearguments,developed

during health impact assessment exercise – helping

theminthenegotiationsintheaccessionprocess”.

Although theWHO provided guidance and technical

assistance,thehealthimpactassessmentoftheCAPtook

longerthan planneddue to theenormousbody of CAP

legislation of CAP[9,34].The health impact assessment

however, createdopportunities forboth theMinistryof

HealthandtheMinistryofAgriculture,FoodandForestry

andenabledinteractionandformulationofanimportant

pillarofFNAP,namelythepartonfoodsupplyand

secu-rity[35].In2004,anewgovernmententeredthesceneand

thenextdirectorgeneralforpublichealth,MarijaSeljak

finalisedthepolicy-makingprocess.Afterfouryearsthe

FNAPwasreadyandwaspresentedtoparliamentanda

resolutiononthenationalprogrammeofnutritionalpolicy

2005–2010wasadopted[36].

4. Discussion

Thefindingsofthisstudysuggestthatthedevelopment

andadoptionofthenationalpolicyinfoodandnutritionin

Slovenialargelycanbeexplainedbyachangeinpolitical

circumstancesthatenabledtheMinistryofHealthandthe

MinistryofAgriculture,FoodandForestrytowork

collab-oratively.Inourstudy,wealsoidentifiedthatindividuals,

bothoutsideandinsidetheSloveniangovernment,

consid-erablycontributedtoraisingnutritionasapoliticalissue

andthedevelopmentofanationalnutritionpolicy.These

findingshighlighttheimportantroleofindividualsinthe

policy-makingprocess throughtheiranalytical,strategic

andpoliticalpolicyentrepreneurialskills.Ifthese

individu-alshadnotparticipated,itisquestionablewhetherSlovenia

wouldhaveadoptedafoodandnutritionpolicyatthattime.

Theanalyticalroleduringproblemidentificationwas

mainly attributed toindividuals who collected data on

theprevalenceofnon-communicablediseasesand

repeat-edlycommunicatedthesescientificfindingstohighrank

officials. Respondents in Sweden and Finlanddiscussed

theimportanceofnutritionmonitoringinPHNto

main-taintheinterestofpolicy-makersandmedia.Theactions

implementedbythesehealthandmedicallytrained

indi-vidualsparticularlytheorganisationoflargesurveysand

conferencesfrom1990to1995,wereimportantinbringing

nutritionissuestotheattentionofpoliticians(cf.[11]).This

suggeststhatusingnationaldatatocommunicatehealth

issuesandnutritionriskfactorscancapturepolitical

inter-estandinfluencethepoliticalagendaandpolicychange.

Thestrategicroleinthepolicysolutionprocessinvolves

differentfunctionstotheanalytical role intheproblem

identification.Firstly,thegrowingdiscontentwiththe

par-liamentarystructure torespondtothegrowingissueof

non-communicablediseases,ledasmallSlovenenetwork

tosearchforpolicysolutionsintheinternationalarena.

Thisshowsthatanimportantpolicysolutionapproachis

notonlytoquestionthewayapolicyisadministeredbut

tostrategicallysearchfornewpolicysolutionsabroad.

Sec-ondly,fromthemid-1990stherewasfrequentinteraction

betweenexpertsfromtheWHO,publichealthnutrition

academics,NationalPublicHealthInstitutesandthe

inter-nationalCINDI network.In this sense,thestrategicrole

demonstratedneedtojoinexpertstocreatea

knowledge-basednetworkthatcouldsupportaction.Respondentsin

Swedenalsohighlightedthis importanceofprofessional

supportnetworksandnotedthateventsorganisedbythe

WHOwereparticularlyuseful.TheWHOEuropeanregional

office was identified as an important policy actor who

supportedmemberstateswithlinkingnutritionandfood

issuestopoliticalpriorities[24,26,27].Acrucialaspectof

developingpolicysolutionsislearningfromthe

interna-tional community. This is a strategic approach because

policiesandideasfromtheinternationalcommunity,such

asthosefromtheWHO,reflectauthorityandexpertiseand

havebeenusedpreviouslytoinfluencedomestic

agenda-setting[37].

The final role exploredin theSlovenian example of

nutritionpolicydevelopmentisthatofpolicyentrepreneur.

Acrucialfunctionofpolicydevelopmentistiming,which

in this case meant taking advantage of major political

changes.TheformerCINDI directorwasappointedstate

secretaryintheMinistryofHealthin2001andwiththat

appointmentthedevelopmentofanationalactionplanin

publichealthnutritionprogressed.Thewindowof

oppor-tunitytoengagepreviousopponentstothisplancamewith

theaccessionofSloveniatotheEUandtheobligationto

conformtoCAPregulations.Theexerciseofconductinga

96 S.Kugelbergetal./HealthPolicy107 (2012) 91–97

forboththeMinistryofHealthandtheMinistryof

Agri-culture,FoodandForestrytosupportmultisectoralpolicy

development,wheretheobjectivesofbothministrieswere

met.Here politicalnegotiationand thinkingbeyondthe

agendaofnutritionwasnecessarytoenlistthe

participa-tionandsupportofotherinfluentialsectors.Osbornetal.

havealsosuggested thatakeyfunctionofpolicyhealth

reformispoliticalnegotiationandtheabilitytojoin

net-workstogether,bothinterpersonalandinter-sectoral[38].

ThehealthimpactassessmentoftheCAPinthisexample

inSlovenia createdanopportunity forpolitical

negotia-tiontoaligndifferentviewsandformacommongoal.The

effectofconductingahealthimpactassessment,intermsof

creatingintersectoralcollaborationandintegratinghealth

intootherpolicysectorshavebeenextensivelyreported

earlier[9,35,39–44].Itisclearlyessentialtomergeinterests

andknowledgetoacommonpolicyforsuccessfulpolicy

developmentandendorsement.

Toraiseanissuetothepoliticalagendaischallenging.

TheKingdon’sstreams modelhashelped usunderstand

how an issue – with relatively low political priority –

canrisetobepartofthegovernmentalagenda.Kingdon’s

streamsmodelhasbeenwidelyappliedinprevious

pol-icyanalysisstudiesthathaveexploredthekeyaspectsof

politicalagenda-settingandpolicydevelopment[45–47].

In terms of exploringthe role of individuals in

policy-making,previousstudieshavefocusedonthekeyattributes

ofpolicyentrepreneurinconnectingthestreamsin

King-don’smodel[48,49].Inparticular,thestrategies applied

by policy entrepreneurswhen windowsof opportunity

have been opened [38,50,51]. Thisstudy has applied a

broaderapproachandexaminednotonlytheroleofpolicy

entrepreneurinconjoiningthestreamsbutalso

investi-gatedthecharacteristics ofanalystsand strategists and

how they have contributed to agenda-setting and

pol-icydevelopmentofanationalnutritionplaninSlovenia.

TheadditionalinsightsfromrespondentsinSwedenand

Finlandhavehelpedtoclarifytherolesandfunctionsat

playintheagenda-settingandnutritionpolicy

develop-mentmorebroadly.

4.1. Limitationsandconstraintsofthisstudy

ThecountryofSloveniaisrathersmallwithalimited

numberofactorsinvolvedinpublichealthnutrition

pol-icydevelopment.Thispaperdescribesacasestudyofthe

processofdeveloping anutrition policyin Sloveniaand

theprocess described heremay not betransferrable to

othercountries.Theremaybeevents,meetingsand

docu-mentsthatwehaveoverlookedinthisassessment.Wedid

however,reachedanumberofkeyactorsandobservers

presentduringthecriticalperiodofdevelopingthis

pol-icyinSlovenia,andwehaveidentifiedasimilarsequence

anddescriptionofeventsfromseveralrespondents.Weare

thereforereasonablyconfidentthatwehavedescribedthis

policyprocesswithahighlevelofaccuracy.

5. Conclusion

The most important conclusion of this study is

that individual contribution to the agenda-setting and

policydevelopmentprocesstakedifferentroles:

analyti-cal,strategicandpolicyentrepreneur.Themainfunctionof

eachrolerespectivelywastocommunicatescientific

find-ingstopolicy-makers,promotepolicysolutionsfromthe

WorldHealthOrganisation andtakeadvantageofmajor

politicalchangestoenlisttheparticipationandsupportof

previouspolicyopponents.Therolesandfunctions

iden-tified in this study can be used to compare individual

capacity in othercontextsand policy sectors.The main

advantageofapplyingKingdon’sstreamsmodelwasto

sys-tematicallyassessindividualskillsinthreekeyphasesof

thepolicyprocess.Theanalysisinthispaperisrestricted

totheindividuallevelandfutureresearchshouldaddress

howcultural,structuralandinstitutionalnormsalsoaffect

thedevelopmentofnationalpoliciestoaddressimportant

publichealthnutritionissues.

Authors’disclosure

SusannaKugelbergtookaleadroleinstudydesign,data

collection,analysis,draftingand editingthemanuscript.

Agneta Yngve contributed to thestudy design, drafting

andfinaleditingofthismanuscript.KristinaJönsson

con-tributedtothedraftingandfinaleditingofthismanuscript.

Acknowledgements

WewishtothanktherespondentsinSlovenia,Sweden

and Finlandfortheirhelpwiththisworkand toAileen

Robertsonforhervaluablecomments.

References

[1]TrübswasserU,BrancaF.NutritionpolicyistakingshapeinEurope. PublicHealthNutrition2009;12:295–306.

[2] MilioN.Towardhealthylongevity:lessonsinfoodandnutrition pol-icydevelopmentfromFinlandandNorway.ScandinavianJournalof PublicHealth1991;19:209–17.

[3]KjærnesU.FoodandnutritionpoliciesofNordiccountries:how havetheybeen developedandwhat evidencesubstantiatesthe developmentofthesepolicies?ProceedingsoftheNutritionSociety 2003;62:563–70.

[4]NancyM.Promotinghealththroughstructuralchange:analysisof theoriginsandimplementationofNorway’sfarm-food-nutrition policy.SocialScience&MedicinePartA:MedicalPsychology& Med-icalSociology1981;15:721–34.

[5]GibsonL.Theinitiationofnationalnutritionpolicies:acomparative studyofNorwayandGreece:byElisabetHelsingStyxPublications, Groningen,theNetherlands,1990,206pp.(plus94ppinabridged Greekversion),Dfl96.00.FoodPolicy1992;17:249–50.

[6]Zaletel-KrageljL,FrasZ,ZakotnikJ.ResultsofCINDIHealthMonitor surveysinSloveniaasatoolfordevelopmentofeffectivehealthy nutritionandphysicalactivityinterventionprogrammes.Journalof PublicHealth2006;14:110–8.

[7]Zaletel-KrageljL,ErzenI,FrasZ.Interregionaldifferencesinhealth inSloveniaI.Estimatedprevalenceofselectedcardiovascularand relateddiseases.CroatianMedicalJournal2004;45(5):637–43. [8]Zaletel-KrageljL,ErzenI,FrasZ.Interregionaldifferencesinhealth

inSloveniaII.Estimatedprevalenceofselectedbehavioralrisk fac-torsforcardiovascularandrelateddiseases.CroatianMedicalJournal 2004;45(5):644–50.

[9]LockK,Gabrijelcic-BlenkusM,MartuzziM,OtorepecP,WallaceP, DoraC,etal.Healthimpactassessmentofagricultureandfood poli-cies:lessonslearntfromtheRepublicofSlovenia.Bulletinofthe WorldHealthOrganization2003;81:391–8.

[10]JobnutProjectGroup.Promotingthepublichealthnutrition work-forceinEurope.StockholmandOslo;2012.

[11]KingdonWJ.Agendas,alternatives,andpublicpolicies.Boston:Little Brown;1984.

[12]KvaleS,BrinkmannS.Denkvalitativaforskningsintervjun.Lund: Stu-dentlitteratur;2008.

[13] WeindlingP.Publichealthandpoliticalstabilisation:theRockefeller FoundationinCentralandEasternEuropebetweenthetwoworld wars.Minerva1993;31:253–67.

[14]Albreht T, KlazingaNS. Restructuringpublic health inSlovenia between1985 and2006. InternationalJournal ofPublicHealth 2008;53:150–9.

[15] Bulc M, Å vab I, Yaphe J. The countrywide integrated non-communicabledisease interventionprogramme(CINDI)andthe effectsofhealthcaresystemreforminSlovenia.EuropeanJournal ofGeneralPractice2001;7:154–60.

[16] SelbJ,KravanjaM.AnalizaumrljivostivSlovenijivletih1987do 1996[MortalityrateanalysisinSlovenia1987to1996].ZdravVarst 2000;39:5–18.

[17] KochV.PrehrambenenavadeodraslihprebivalcevSlovenijezvidika varovanjazdravja.(NutritionhabitsoftheadultSlovenepopulation fromhealthperspective).PhDthesis.Biotehniˇskafakulteta:Univerza vLjubljani;1997.

[18]WHORegionalOfficeforEurope.CINDIhighlights1994.Copenhagen; 1994.

[19]WorldHealthOrganisation.Worlddeclarationandplanofactionfor nutrition.Geneva;1992.

[20]NationalHealthPlan‘Healthforallbytheyear2004[Nacionalni program‘Zdravjezavsedoleta2004’].Ljubjana;2000.

[21]WorldHealthOrganization.Globalstrategyforhealthforallbythe year2000.Geneva;1981.

[22]HelsingE.NutritionpoliciesinEurope:backgroundandorganization. FoodPolicy1991;16:371–82.

[23]WHORegionalCommitteeforEurope.Theimpactoffoodand nutri-tiononpublichealth:thecaseforafoodandnutritionpolicyand anactionplanfortheEuropeanregionofWHO2000–2005. Copen-hagen;2000.

[24]WHORegionalOfficeforEurope.Thefirstactionplanforfoodand nutritionpolicyWHOEuropeanregion2000–2005.Copenhagen; 2001.

[25]RobertsonA,JerminiM.Towardshealthierfoodpolicies?Anew actionplanforEurope.PublicHealthNutrition2001;4:85–6. [26] WHORegionalOfficeforEurope.Intersectoralfoodandnutrition

pol-icydevelopment:amanualfordecision-makers.Copenhagen;2001. [27]WHORegionalOfficeforEurope.Developmentoffoodand nutri-tionactionplansincountriesofSouth-EastEurope:reportonathird workshop.Copenhagen;2002.

[28] WHORegionalOfficeforEurope.CINDIdietaryguide.Copenhagen; 2000.

[29]KafatosA,CodringtonCA.Nutritionanddietforhealthylifestyles inEurope:the‘Eurodiet’Project.JournalofPublicHealthNutrition 2001;4.2(a)and2(b).

[30]CounciloftheEuropeanUnion.Councilresolutionof14December 2001onhealthandnutrition.OfficialJournaloftheEuropean Com-munities2001;C20:1–2,2001/C20/01.

[31]RepublicofSloveniaNationalAssembly.Nationalprogramforhealth fortheRepublicofSlovenia–Healthforallbytheyearof2004. Ljubjana;2000.

[32] SchäferElinderE.HIApublichealthaspectsoftheEUcommon agri-culturalpolicy.Stockholm;2003.

[33]ElinderLS.PublichealthshouldreturntothecoreofCAPreform. EuroChoices2003;2:32–6.

[34]MinistryofHealth.Healthimpactassessmentoffoodand agricul-turepoliciesinSloveniaandthepotentialeffectofaccessiontothe EuropeanUnion.Ljubjana;2004.

[35]GabrijelˇciˇcBlenkuˇsM,ScagnettiN.Usingintersectoralnetworks towardstheadoptionoftheCommonAgriculturalpolicy:anHIA ontheFoodandNutritionActionPlaninSlovenia.In:WismarM, BlauJ,ErnstK,FigurerasJ,editors.Theeffectivenessofhealthimpact assessment:scopeandlimitationsofsupportingdecision– making inEurope.Copenhagen:WHOonthebehalfoftheEuropean Obser-vatoryonHealthSystemsandPolicies;2007.

[36]RepublicofSloveniaNationalAssembly.Resolucijaonacionalnem programuprehranskepolitike2005–2010Ur.l.RS, ˇst.39/2005 [Res-olutiononnationalprogramofnutritionalpolicy2005–2010OGNo. 39/2005]Ljubljana;2005.

[37]BuschP-O,JörgensH.Theinternationalsourcesofpolicy conver-gence:explainingthespreadofenvironmentalpolicyinnovations. JournalofEuropeanPublicPolicy2005;12:860–84.

[38]ObornE,BarrettM,ExworthyM.Policyentreprenurshipinthe devel-opmentofpublicsectorstrategy:thecaseofLondonhealthreform. PublicAdministration2011;89:325–44.

[39] Davenport C, MathersJ, Parry J. Useof health impact assess-ment in incorporating health considerations in decision mak-ing. Journal of Epidemiology and Community Health 2006;60: 196–201.

[40] DoraC,RacioppiF.Includinghealthintransportpolicyagendas: theroleofhealthimpactassessmentanalysesandproceduresin theEuropeanexperience.BulletinoftheWorldHealthOrganization 2003;81:399–403.

[41]DouglasMJ,ConwayL,GormanD, GavinS,HanlonP.Achieving betterhealththroughhealthimpactassessment.HealthBulletin 2001;59:300–5.

[42]LeeK,IngramA,LockK,McInnesC.Bridginghealthandforeign pol-icy:theroleofhealthimpactassessments.BulletinoftheWorld HealthOrganization2007;85:207–11.

[43]Mannheimer LN,Gulis G, Lehto J, Ostlin P. IntroducingHealth Impact Assessment: an analysis ofpolitical and administrative intersectoralworkingmethods.EuropeanJournalofPublicHealth 2007;17:526–31.

[44]MindellJ,SheridanL,JoffeM,Samson-BarryH,AtkinsonS.Health impactassessment asanagentofpolicychange:improvingthe health impactsof themayorof London’sdraft transport strat-egy. Journal of Epidemiology and Community Health2004;58: 169–74.

[45]FelixHC.Theriseofthecommunity-basedparticipatoryresearch initiativeattheNationalInstituteforEnvironmentalHealthSciences: anhistoricalanalysisusingthepolicystreamsmodel.Progressin CommunityHealthPartnerships2007;1:31–9.

[46]GladwinCP,ChurchJ,PlotnikoffRC.Publicpolicyprocessesand get-tingphysicalactivityintoAlberta’surbanschools.CanadianJournal ofPublicHealth2008;99:332–8.

[47] OllilaE.Healthinallpolicies:fromrhetorictoaction.Scandinavian JournalofPublicHealth2011;39:11–8.

[48]BlumenthalD.Portraitofapolicyandpoliticalentrepreneur.Health Affairs2009;28:w1037–9.

[49]Whitehead D. The health-promoting nurse as a health policy careerexpertandentrepreneur.NurseEducationToday2003;23: 585–92.

[50] GuldbrandssonK,FossumB.Anexplorationofthetheoretical con-ceptspolicywindows andpolicyentrepreneurs attheSwedish public health arena. Health Promotion International 2009;24: 434–44.

[51]MannheimerLN,LehtoJ,Ã-stlinP.Windowofopportunityfor inter-sectoralhealthpolicyinSweden:open,half-open orhalf-shut? HealthPromotionInternational2007;22:307–15.