Regional strategies for tackling Health InequalitiesRegional strategies for tackling Health Inequalities

Luigi Bertinato MDLuigi Bertinato MDDirector, External Affairs Office, Director, External Affairs Office, Department of Health & Social Services, Department of Health & Social Services, Veneto Region, Venice, ITALYVeneto Region, Venice, ITALY

European Health Forum Gastein 2009European Health Forum Gastein 2009

Parallel Forum 3 Parallel Forum 3 –– Session 1Session 1TACKLING HEALTH INEQUALITIES IN EUROPE TACKLING HEALTH INEQUALITIES IN EUROPE EU POLICY & RESEARCH EU POLICY & RESEARCH –– CLOSING THE GAPCLOSING THE GAP

BackgroundBackgroundThe process of political decentralization of health care The process of political decentralization of health care systems and public health systems to the Regions in Europe systems and public health systems to the Regions in Europe moves alongside the current debate on the right of European moves alongside the current debate on the right of European citizens to equal access to health and social services in the 27citizens to equal access to health and social services in the 27Member States;Member States;

25% of European countries have a population of <5 million 25% of European countries have a population of <5 million inhabitants corresponding to many of the average sized inhabitants corresponding to many of the average sized European Regions. ThreeEuropean Regions. Three--quarters of MS have decentralized quarters of MS have decentralized their public health systems;their public health systems;

There is a need to harmonize public policies to cope with the There is a need to harmonize public policies to cope with the free movement of citizens and patients in the EU, and to free movement of citizens and patients in the EU, and to address new demographic trends, eg. the increasing ageing address new demographic trends, eg. the increasing ageing population, increasing poverty, and the rising influx of nonpopulation, increasing poverty, and the rising influx of non--EU EU immigrants.immigrants.

L. Bertinato, Veneto Region

Benchmarking Regional Health Management IIBenchmarking Regional Health Management II (Courtesy of Helmut Brand)

The ongoing collaboration of the European Regions: The ongoing collaboration of the European Regions: Example of BEN II EU projectExample of BEN II EU project

Västsverige

Kaunas

England

Saxony-Anhalt

North Rhine-W estphalia

M oravia-Silesian Flem ish Com m unity

Southern and Eastern Ireland

Upper Austria

Nyugat-Dunántúl

Eszak-Alföld

Veneto

Em ilia-Rom agna

Sicily

W estern Greece

M adeira

Cluster 1. Cluster 2. Cluster 3. Cluster 4.

Regions

Participating on Ben RHM II

Regions NUTS 2 Grouped in Clusters

NUTS Level

Region NUTS 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-

Sopron County 2 Nygat-Dunántúl

2 Szabolcs-Szatmár

2 Észak-Alföld

2 Upper-Austria 2 Upper-Austria 2 Madeira 2 Madeira 3 Västra Götaland 2 Västsverige 3 Varna Oblast 2 Ticino -- Chuvash -- Vologda

Veneto RegionVeneto Region’’s Membership of European Regional Networkss Membership of European Regional Networks

Armenia SunikAustria CarinthiaBelgium Flemish CommunityBulgaria VarnaCzech Republic Usti

Silesia-MoraviaGermany Lower Saxony

North Rhine-WestphaliaHungary Bács Kiskun

Györ Moson SopronSzabolcs-Szatmár

Israel Northern RegionItaly Emilia Romagna

SicilyP.A. BolzanoVeneto

Lithuania KaunasNorway RogalandPoland SilesiaPortugal MadeiraRomania Timis (new)Russia VologdaSpain Catalonia

ValenciaSweden Västra Götaland

ÖstergötlandSwitzerland TicinoUnited Kingdom North West England

Northern Ireland, Wales

ALPS ADRIATIC ALPS ADRIATIC WORKING COMMUNITYWORKING COMMUNITY

WHOWHO Regions for Health Network, EuropeRegions for Health Network, Europe

L. Bertinato, Veneto Region

The Veneto Region The Veneto Region Population Structure (as of the 2001 General Consensus)Population Structure (as of the 2001 General Consensus)

VENETOVENETO ITALYITALY

Total population:Total population: 4,832,340 4,832,340 59,619,29059,619,290Surface areaSurface area 18,390 Kmq18,390 KmqN. Families:N. Families: 1,699,2351,699,235 21,503,08821,503,088

Members per family: 2.62Members per family: 2.62 2.602.60Birth rate:Birth rate: 9.3 9.29.3 9.2Death rate: 9.0 9.5Death rate: 9.0 9.5Natural growth rate 0.3 Natural growth rate 0.3 --0.20.2Total growth rate: 5.6 1.9 Total growth rate: 5.6 1.9

Structure of the elderly populationStructure of the elderly populationN. Elderly people in the Veneto: N. Elderly people in the Veneto: 927,051 927,051 Population > 65 years: Population > 65 years: 19.4% 19.4% (compared to a EU average of 14.08%)(compared to a EU average of 14.08%)

Elderly personsElderly persons’’ indexindex 138.9 Hospitalisation index 108.80138.9 Hospitalisation index 108.80Dependency indexDependency index 50.150.1 SelfSelf--sufficiency index 50.10sufficiency index 50.10

Exchange index Exchange index 128.9128.9Health facilities indexHealth facilities index 108.8108.8

Total Veneto production facilities as of 2008Total Veneto production facilities as of 2008:: 462,567462,567 * * ((**high proportion of smallhigh proportion of small--medium medium sized and familysized and family based companies)based companies)

Life Life expectancy at expectancy at birthbirth

Life Life expectancy expectancy at 60 yearsat 60 years

Probability of Probability of death at 0 yrsdeath at 0 yrs

Median age at Median age at deathdeath

DisabilityDisability

M F M F M F M F

VENETOVENETO 77,5 83,8 20,9 25,8 3,3 2,3 80,3 86,5 4,2

ITALYITALY 77,2 82,8 20,8 25 4,4 3.7 80,1 85,5 4.8

Synthesis of health and mortality indicatorsSynthesis of health and mortality indicators

(ISTAT DATA 2008)

Incidence of Relative Poverty (IP) in VenetoIncidence of Relative Poverty (IP) in Venetoin 2008 was in 2008 was 3.3 %3.3 % compared to compared to 11.1%11.1% in Italy and in Italy and the lowest after Lombardy. Estimated the lowest after Lombardy. Estimated n. poor people in the Veneto Region =n. poor people in the Veneto Region =159,390159,390(total population of (total population of 4,832,3404,832,340))

““Relative povertyRelative poverty”” refers to a family of 2 refers to a family of 2 members with a mean monthly consumption members with a mean monthly consumption expenditure of expenditure of ≤≤ €€ 986.35986.35

The average annual income of Veneto families is €€30,15130,151, around €€2,5002,500 a month, compared to the national average of €€28,55228,552

RELATIVE POVERTY IN THE RELATIVE POVERTY IN THE ITALIAN REGIONS: Year 2007ITALIAN REGIONS: Year 2007

Source: ISTAT – Veneto Region Statistics Office, 2008

Veneto Region Health ModelVeneto 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

Department of Health & Social Services

21 Local Health Authorities:

56 LHUs

2 University Hospitals

581 Municipalities in the Veneto

Region

The Regional Health & Social Care PlanThe 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, Granting system equity, overcoming social and local divisions, promoting accessibility for disadvantaged people, ensuring promoting accessibility for disadvantaged people, ensuring proper care.proper care.

Integration between Health & Social Sectors of the Integration between Health & Social Sectors of the the Region and Municipalities to address Health Inequalitiesthe Region and Municipalities to address Health Inequalities

581581 MUNICIPALITIESMUNICIPALITIES 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

Community Health Plans (CHP) are developed between each of the 21 local health units and 581 municipalitiies of the territory

Areas of the Community Health Plan with a strong strong integration between the Health integration between the Health and Social Services and Social Services focus on:

The elderlyThe disabledYoung people and their familiesDrug and alcohol preventionMental healthSocially excluded peopleImmigrants

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 Local health authorities and the municipal board of mayorsboard of mayors

Regional Investment in Health & Social ServicesRegional Investment in Health & Social Services•• Regional budget allocation for Healthcare in Regional budget allocation for Healthcare in 20082008: : €€7.3 Billion7.3 Billion

•• Regional investment allocated to the Social Sector:Regional investment allocated to the Social Sector:

For non self-sufficient,

mainly elderly citizens and

other vulnerable population

groups

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

€€620 M620 M

The elderly population in Veneto : critical Issues…

Increasing aging of the population ( 19,4% )Senile dementia: an increasing phenomenonLoss of autonomySocial Exclusion:

Access to servicesIsolationPoverty

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 Regional actions to tackle social exclusion in the health sectorin the health sector

For selfFor self--sufficient, elderly citizenssufficient, elderly citizensDistribution of emergency telephone dialers to a total of 20,000Distribution of emergency telephone dialers to a total of 20,000 elderly people living at home elderly people living at home in the Veneto Region, financed by the Region in the Veneto Region, financed by the Region -- €€5,164,568.99;5,164,568.99;The opportunity to attend university courses under the The opportunity to attend university courses under the ““University of the Golden YearsUniversity of the Golden Years””project at the Universities of Padua and Verona.project at the Universities of Padua and Verona.

For acute, non selfFor acute, non self--sufficient elderly citizens:sufficient elderly citizens:Development of a network of residential care services: 270 facilDevelopment of a network of residential care services: 270 facilities equipped with 26,000 ities equipped with 26,000 beds;beds;Integration between residential home care and home care; Integration between residential home care and home care; Experimentation with Experimentation with ““community care hospitalscommunity care hospitals””; ; Reinforcement of the home care network, with a focus on home nurReinforcement of the home care network, with a focus on home nursing, rehabilitation and sing, rehabilitation and care;care;

For lowFor low--income groups, reducing the cost of pharmaceuticals:income groups, reducing the cost of pharmaceuticals:

Total n. citizens exempt from paying for prescriptions is 1,454,Total n. citizens exempt from paying for prescriptions is 1,454,919 or 31.43% of the Veneto 919 or 31.43% of the Veneto population. population.

Examples where Regional policies have affected Examples where Regional policies have affected health inequalitieshealth inequalities

For the disabledFor the disabledProgrammes to guarantee equal opportunities in the workplace, inProgrammes to guarantee equal opportunities in the workplace, ineducation, to enable easier access to health services;education, to enable easier access to health services;Activation of networks to facilitate home care, focusing on famActivation of networks to facilitate home care, focusing on family care and ily care and

community care programmes;community care programmes;Improvement of public facilities in the Region, eg. sports stadiImprovement of public facilities in the Region, eg. sports stadiums, university ums, university buildings etc. to facilitate access for disabled citizensbuildings etc. to facilitate access for disabled citizens

For lowFor low--income families caring for non selfincome families caring for non self--sufficient family member:sufficient family member:Regional economic support and relief given to such families to pRegional economic support and relief given to such families to pay for a daily ay for a daily caregiver in the homecaregiver in the home

Actions: postnatal & pre-school care

New Regional project: New Regional project: ““nursery in the familynursery in the family”” **Nursery school (3m -3 years)In-company nurseryMicro-nurseryIntegrated nurseryChildren’s centre

*(L.R. 32/90 and 22/02L.R. 32/90 and 22/02)

A new challenge: the inclusion of nonA new challenge: the inclusion of non--EU migrants EU migrants in the Health & Social Systemin the Health & Social System

Foreign workers and professionals in the Veneto with regular staForeign workers and professionals in the Veneto with regular stay permits, included in y permits, included in municipal registry offices was municipal registry offices was 457,000457,000, with an incidence of , with an incidence of 9.3%. 9.3%. (Istat 2007)(Istat 2007)

The incidence of immigrants on the Italian population is The incidence of immigrants on the Italian population is 5.2%5.2% amounting to 1 immigrant amounting to 1 immigrant out of 19 residents (1 out of 14 in the Northeast) (Caritas 200out of 19 residents (1 out of 14 in the Northeast) (Caritas 2006)6)

According to the 2001 General Consensus: According to the 2001 General Consensus: 7.9%7.9% of the migrant population of Italy lives of the migrant population of Italy lives in the Veneto; only considering nonin the Veneto; only considering non--EU citizens, that figure rises to EU citizens, that figure rises to 12%12%

05.000

10.00015.00020.00025.00030.00035.00040.000

2004 2006 2008

Nr. Non-EUworkersrequired

IntroducesIntroduces the concept of an integrated Plan for Social the concept of an integrated Plan for Social Inclusion by overcoming sectorial interventions Inclusion by overcoming sectorial interventions according to target population;according to target population;

OvercomesOvercomes the the ““call for bidscall for bids”” logic by allocating logic by allocating finances according to predefined criteria, so that the finances according to predefined criteria, so that the project can refer project can refer to definite sources of financingto definite sources of financing; ;

EvaluatesEvaluates, , capitalizescapitalizes and and promotespromotes the model the model expressed by the expressed by the synergy between regional planning and synergy between regional planning and local project developmentlocal project development, experimented thanks to , experimented thanks to financing made available (art.28 L. 328/00) financing made available (art.28 L. 328/00)

Regional Health & Social Plan for Social Inclusion 2008Regional Health & Social Plan for Social Inclusion 2008

ActivatesActivates a process of integration of the various areas a process of integration of the various areas of intervention which promote locally based of intervention which promote locally based collaboration among different subjects; collaboration among different subjects;

GuaranteesGuarantees in each provincial territory the in each provincial territory the development of a development of a model of partnership model of partnership and coand co--project project development among development among public and nonpublic and non--profit organizationsprofit organizations, , in favour of the vulnerable groups; in favour of the vulnerable groups;

PreventsPrevents the fragmentation of financial resources the fragmentation of financial resources among a plurality of beneficiaries and their inefficacy.among a plurality of beneficiaries and their inefficacy.

Regional Health & Social Plan for Social Inclusion 2008Regional Health & Social Plan for Social Inclusion 2008

The Regional Observatory of Social Marginalisation in the oweraThe Regional Observatory of Social Marginalisation in the owerall ll Veneto Strategy to tackle Health Inequalities as per todayVeneto Strategy to tackle Health Inequalities as per today

……supportssupports……..

Regional Planning ActionRegional Planning Action

Setting up a monitoring systemSetting up a monitoring system

Setting up of an evaluation system of Setting up of an evaluation system of interventionintervention

Development of a regional social Development of a regional social information systeminformation system

The contribution of the European Regions to reduce The contribution of the European Regions to reduce Inequalities:Inequalities:

DECENTRALISATIONDECENTRALISATION in order to improve efficiency (by in order to improve efficiency (by transferring responsibilities to providers) and ensuring transferring responsibilities to providers) and ensuring that, if there are inequalities, they are that, if there are inequalities, they are ‘‘acceptableacceptable’’ (by (by choice or being local communities financially choice or being local communities financially accountable after the central levelling of resources)accountable after the central levelling of resources)

Courtesy of Guillem López-Casasnovas 2009

Conclusions Conclusions -- 11European CoEuropean Co--operation between Regions, Municipalities and operation between Regions, Municipalities and Member States in the area of inequalities becomes urgent for Member States in the area of inequalities becomes urgent for the future of an enlarged Europe; the future of an enlarged Europe;

Adapting common Regional Health & Social Care strategies to Adapting common Regional Health & Social Care strategies to new demographic trends new demographic trends in the shortin the short--term term can help reduce can help reduce widespread inequalities;widespread inequalities;

Programmes to tackle health inequalities cannot waitProgrammes to tackle health inequalities cannot wait; ;

Access to health and social services for EU and nonAccess to health and social services for EU and non--EU EU immigrants is one of the major challenges in the fight to immigrants is one of the major challenges in the fight to address inequalities;address inequalities;

Conclusions Conclusions -- 22The crisis requires in the short term a better targeting of The crisis requires in the short term a better targeting of relatively more needed population with specific flexible relatively more needed population with specific flexible policies which include publicpolicies which include public--private partnership;private partnership;

Subsidiarity , governance and good management of Subsidiarity , governance and good management of specific policies to vulnerable populations can specific policies to vulnerable populations can contribute to reducing health inequalitiescontribute to reducing health inequalities

The Regions, mainly accross the borders, are in the The Regions, mainly accross the borders, are in the frontline in the Health & Social sectors for anticipating frontline in the Health & Social sectors for anticipating methods of collaboration between European Member methods of collaboration between European Member States in an enlarged Europe. States in an enlarged Europe.

L. Bertinato, Veneto Region

THANK YOU FOR YOUR ATTENTION !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 thesubject. 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 dataincluded in this paper, nor does it accept responsibility for any use made thereof.