European Health Forum Gastein 2009 Parallel Forum 3 Session 1 TACKLING HEALTH INEQUALITIES IN EUROPE EU POLICY & RESEARCH CLOSING THE GAP Regional strategies for tackling Health Inequalities Luigi Bertinato MD Director, External Affairs Office, Department of Health & Social Services, Veneto Region, Venice, ITALY
Background The process of political decentralization of health care systems and public health systems to the Regions in Europe moves alongside the current debate on the right of European citizens to equal access to health and social services in the 27 Member States; 25% of European countries have a population of <5 million inhabitants corresponding to many of the average sized European Regions. Three-quarters of MS have decentralized their public health systems; There is a need to harmonize public policies to cope with the free movement of citizens and patients in the EU, and to address new demographic trends, eg. the increasing ageing population, increasing poverty, and the rising influx of non-eu immigrants. L. Bertinato, Veneto Region
The ongoing collaboration of the European Regions: Example of BEN II EU project Southern and Eastern Ireland Madeira England Flemish Community Västsverige North Rhine- Westphalia Veneto Upper Austria Emilia- Romagna Sicily Saxony-Anhalt Moravia-Silesian Kaunas Eszak-Alföld Nyugat-Dunántúl Western Greece Regions Participating on Ben RHM II Regions NUTS 2 Grouped in Clusters NUTS NUTS Region Level Level Region 2 Flemish Community 2 Flemish Community 2 North Rhine- Westphalia 2 North Rhine- Westphalia 2 Saxony-Anhalt 2 Saxony-Anhalt 2 Western Greece 2 Western Greece 2 Dublin 2 Southern & Eastern Ireland 2 Veneto 2 Veneto 2 Emilia-Romagna 2 Emilia- Romagna 2 Sicilia 2 Sicilia 2 Kaunas 2 Kaunas 2 Györ-Moson- 2 Nygat-Dunántúl Sopron County 2 Szabolcs- 2 Észak-Alföld Szatmár 2 Upper-Austria 2 Upper-Austria 2 Madeira 2 Madeira 3 Västra Götaland 2 Västsverige 3 Varna Oblast 2 Ticino -- Chuvash -- Vologda Cluster 1. Cluster 2. Cluster 3. Cluster 4. Benchmarking Regional Health Management II (Courtesy of Helmut Brand)
Veneto Region s s Membership of European Regional Networks WHO Regions for Health Network, Europe Armenia Sunik Austria Carinthia Belgium Flemish Community Bulgaria Varna Czech Republic Usti Silesia-Moravia Germany Lower Saxony North Rhine-Westphalia Hungary Bács Kiskun Györ Moson Sopron Szabolcs-Szatmár Israel Northern Region Italy Emilia Romagna Sicily P.A. Bolzano Veneto Lithuania Kaunas Norway Rogaland Poland Silesia Portugal Madeira Romania Timis (new) Russia Vologda Spain Catalonia Valencia Sweden Västra Götaland Östergötland Switzerland Ticino United Kingdom North West England Northern Ireland, Wales L. Bertinato, Veneto Region ALPS ADRIATIC WORKING COMMUNITY
The Veneto Region Population Structure (as of the 2001 General Consensus) VENETO ITALY Total population: 4,832,340 59,619,290 Surface area 18,390 Kmq N. Families: 1,699,235 21,503,088 Members per family: 2.62 2.60 Birth rate: 9.3 9.2 Death rate: 9.0 9.5 Natural growth rate 0.3-0.2 Total growth rate: 5.6 1.9 Structure of the elderly population N. Elderly people in the Veneto: 927,051 Population > 65 years: 19.4% (compared to a EU average of 14.08%) Elderly persons index 138.9 Hospitalisation index 108.80 Dependency index 50.1 Self-sufficiency index 50.10 Exchange index 128.9 Health facilities index 108.8 Total Veneto production facilities as of 2008: 462,567 * (*high proportion of small-medium medium sized and family based companies)
Synthesis of health and mortality indicators Life expectancy at birth Life expectancy at 60 years Probability of death at 0 yrs Median age at death Disability M F M F M F M F VENETO 77,5 83,8 20,9 25,8 3,3 2,3 80,3 86,5 4,2 ITALY 77,2 82,8 20,8 25 4,4 3.7 80,1 85,5 4.8 (ISTAT DATA 2008)
Incidence of Relative Poverty (IP) in Veneto in 2008 was 3.3 % compared to 11.1% in Italy and the lowest after Lombardy. Estimated n. poor people in the Veneto Region =159,390= (total population of 4,832,340) Relative poverty refers to a family of 2 members with a mean monthly consumption expenditure of 986.35 The average annual income of Veneto families is 30,151, around 2,500 a month, compared to the national average of 28,552 Source: ISTAT Veneto Region Statistics Office, 2008 RELATIVE POVERTY IN THE ITALIAN REGIONS: Year 2007
Veneto Region Health Model Levels of Health and Social integration : Institutional Management and organization Professional
The Veneto s responsibility in policy-making in the Health & Social Sector Minister for Health Policies Minister for Social Policies 21 Local Health Authorities: 56 LHUs Department of Health & Social Services 2 University Hospitals 581 Municipalities in the Veneto Region
The Regional Health & Social Care Plan Promoting healthy lifestyles, and individual and global protection through integrated policies; Granting continuous assistance to the population via network of Hospitals, and Health &social Services in the territory; Reinforcing active involvement of the local community; Granting system equity, overcoming social and local divisions, promoting accessibility for disadvantaged people, ensuring proper care.
Integration between Health & Social Sectors of the the Region and Municipalities to address Health Inequalities 581 MUNICIPALITIES share with the 21 local health units the responsibility of planning the system to provide health and social services to citizens and more vulnerable groups Areas of the Community Health Plan with a strong integration between the Health and Social Services focus on: The elderly The disabled Young people and their families Drug and alcohol prevention Mental health Socially excluded people Immigrants Community Health Plans (CHP) are developed between each of the 21 local health units and 581 municipalitiies of the territory Regular convening of the Permanent Committee between LHU Director Generals & the Conference of Mayors (ratio 1:78) L. Bertinato, Veneto Region
Local health authorities and the municipal board of mayors
Regional Investment in Health & Social Services Regional budget allocation for Healthcare in 2008: 7.3 Billion Regional investment allocated to the Social Sector: For non selfsufficient, mainly elderly citizens and other vulnerable population groups 620 M To provide services to drug addicts For financing other programmes: home care for the elderly; support to families with chronically-ill dependent; telehelp for caregivers; services for the handicapped
The elderly population in Veneto : critical Issues Increasing aging of the population ( 19,4% ) Senile dementia: an increasing phenomenon Loss of autonomy Social Exclusion: Access to services Isolation Poverty
Disability in Veneto : critical issues Characteristics of the disabled population; Increase in acquired disabilities; Social exclusion; Cultural approach to disability; Access to services; Access to work, culture and leisure.
Addiction in Veneto : critical issues Characteristics of the phenomenon of addiction and alcoholism; Adoption of problematic lifestyles; Younger people are most exposed; Widespread use of alcohol among young people.
Regional actions to tackle social exclusion For self-sufficient, sufficient, elderly citizens in the health sector Distribution of emergency telephone dialers to a total of 20,000 elderly people living at home in the Veneto Region, financed by the Region - 5,164,568.99; The opportunity to attend university courses under the University of the Golden Years project at the Universities of Padua and Verona. For acute, non self-sufficient sufficient elderly citizens: Development of a network of residential care services: 270 facilities ities equipped with 26,000 beds; Integration between residential home care and home care; Experimentation with community care hospitals ; Reinforcement of the home care network, with a focus on home nursing, rehabilitation and care; For low-income groups, reducing the cost of pharmaceuticals: Total n. citizens exempt from paying for prescriptions is 1,454,919 or 31.43% of the Veneto population.
Examples where Regional policies have affected health inequalities For the disabled Programmes to guarantee equal opportunities in the workplace, in education, to enable easier access to health services; Activation of networks to facilitate home care, focusing on family care and community care programmes; Improvement of public facilities in the Region, eg. sports stadiums, university buildings etc. to facilitate access for disabled citizens For low-income families caring for non self-sufficient sufficient family member: Regional economic support and relief given to such families to pay p for a daily caregiver in the home
Actions: postnatal & pre-school care New Regional project: nursery in the family * Nursery school (3m -3 years) In-company nursery Micro-nursery Integrated nursery Children s centre *(L.R. 32/90 and 22/02)
A new challenge: the inclusion of non-eu migrants in the Health & Social System Foreign workers and professionals in the Veneto with regular stay y permits, included in municipal registry offices was 457,000,, with an incidence of 9.3%. (Istat 2007) The incidence of immigrants on the Italian population is 5.2% amounting to 1 immigrant out of 19 residents (1 out of 14 in the Northeast) (Caritas 2006) According to the 2001 General Consensus: 7.9% of the migrant population of Italy lives in the Veneto; only considering non-eu citizens, that figure rises to 12% 40.000 35.000 30.000 25.000 20.000 15.000 10.000 5.000 0 2004 2006 2008 Nr. Non- EU workers required
Regional Health & Social Plan for Social Inclusion 2008 Introduces the concept of an integrated Plan for Social Inclusion by overcoming sectorial interventions according to target population; Overcomes the call for bids logic by allocating finances according to predefined criteria, so that the project can refer to definite sources of financing; Evaluates, capitalizes and promotes the model expressed by the synergy between regional planning and local project development,, experimented thanks to financing made available (art.28 L. 328/00)
Regional Health & Social Plan for Social Inclusion 2008 Activates a process of integration of the various areas of intervention which promote locally based collaboration among different subjects; Guarantees in each provincial territory the development of a model of partnership and co-project development among public and non-profit organizations, in favour of the vulnerable groups; Prevents the fragmentation of financial resources among a plurality of beneficiaries and their inefficacy.
The Regional Observatory of Social Marginalisation in the owerall Veneto Strategy to tackle Health Inequalities as per today supports. Regional Planning Action Setting up a monitoring system Setting up of an evaluation system of intervention Development of a regional social information system
The contribution of the European Regions to reduce Inequalities: DECENTRALISATION in order to improve efficiency (by transferring responsibilities to providers) and ensuring that, if there are inequalities, they are acceptable (by choice or being local communities financially accountable after the central levelling of resources) Courtesy of Guillem López-Casasnovas 2009
Conclusions - 1 European Co-operation operation between Regions, Municipalities and Member States in the area of inequalities becomes urgent for the future of an enlarged Europe; Adapting common Regional Health & Social Care strategies to new demographic trends in the short-term term can help reduce widespread inequalities; Programmes to tackle health inequalities cannot wait; Access to health and social services for EU and non-eu immigrants is one of the major challenges in the fight to address inequalities;
Conclusions - 2 The crisis requires in the short term a better targeting of relatively more needed population with specific flexible policies which include public-private private partnership; Subsidiarity, governance and good management of specific policies to vulnerable populations can contribute to reducing health inequalities The Regions, mainly accross the borders, are in the frontline in the Health & Social sectors for anticipating methods of collaboration between European Member States in an enlarged Europe. L. Bertinato, Veneto Region
THANK YOU FOR YOUR ATTENTION! luigi.bertinato@regione.veneto.it
This paper was produced for a meeting organized by Health & Consumers DG and represents the views of its author on the subject. These views have not been adopted or in any way approved by the Commission and should not be relied upon as a statement of the Commission's or Health & Consumers DG's views. The European Commission does not guarantee the accuracy of the data included in this paper, nor does it accept responsibility for any use made thereof.