BACKGROUND: It is unknown whether European countries differ systematically in their pursuit of health policies, and what the determinants of these differences are. In this article, we assess the extent to which European countries vary in the implementation of health policies in 10 different areas, and we exploit these variations to investigate the role of political, economic and social determinants of health policy. DATA AND METHODS: We reviewed policies in the field of tobacco; alcohol; food and nutrition; fertility, pregnancy and childbirth; child health; infectious diseases; hypertension detection and treatment; cancer screening; road safety and air pollution. We developed a set of 27 'process' and 'outcome' indicators, as well as a summary score indicating a country's overall success in implementing effective health policies. In exploratory regression analyses, we related these indicators to six background factors: national income, survival/self-expression values, democracy, government effectiveness, left-party participation in government and ethnic fractionalization. RESULTS: We found striking variations between European countries in process and outcome indicators of health policies. On the whole, Sweden, Norway and Iceland perform best, and Ukraine, Russian Federation and Armenia perform worst. Within Western Europe, some countries, such as Denmark and Belgium, perform significantly worse than their neighbours. Survival/self-expression values and ethnic fractionalization were the main predictors of the health policy performance summary score. National income, survival/self-expression values and government effectiveness were the main predictors of countries' performance in specific areas of health policy. CONCLUSIONS: Although many new preventive interventions have been developed, their implementation appears to have varied enormously among European countries. Substantial health gains can be achieved if all countries would follow best practice, but this probably requires the removal of barriers related to both the 'will' and the 'means' to implement health policies.