Health in Italy in the 21St Century

Home , Health in Italy, Provinces of Italy, Rosy Bindi, Troina

FOREWORD

Rosy Bindi Minister of Health of Italy

Roma, September 1999

This report provides the international community with an overall assessment of the state of health in Italy, as well as with the main developments of the Italian public health policy expected in the near future. It is intended as an important contribution towards the activities which, beginning with the 49th WHO Regional Committee in Florence, will be carried out in Europe with a view to defining health policies and strategies for the new century.

This publication, which consists of two sections, illustrates the remarkable health achievements of Italy as regards both the control of diseases and their determinants, and the health care services. Overall, a clearly positive picture emerges, which is due not only to the environmental and cultural characteristics of Italy, but also to its health protection and care system which Italy intends to keep and indeed to improve in the interest of its citizens.

The recent decisions taken in the framework of the reform of the National Health System in Italy intend to improve and strengthen the model of a universal health system based on equity and solidarity, which considers health as a fundamental human right irrespective of the economic, social and cultural conditions of each citizen. The new national health service guarantees, through its public resources, equal opportunities for accessing health services as well as homogenous and essential levels of health care throughout the country. Such a reorganization of the system has become necessary in order to meet new and growing demands for health within the framework of limited resources and with the understanding that equity in health is not only an ethical requirement, but also a rational and efficient way for allocating resources.

We truly believe that health consumerism- does not lead to greater and better health care, but rather exhausts resources and increases inequity.

Yet, given that the real challenge over the next years will be the provision of an extended health protection, it is necessary to bring about significant changes to the health care system through strengthening of prevention, rehabilitation and integration of the social and health dimensions, as well as the role of citizens and health professionals in promoting the process of change. This means, in essence, moving the focus of the policy from treating- to taking care- of the sick in a broader perspective, which is more consistent with the World Health Organization's definition of health as physical, psychological and social well-being. This is also the direction outlined in the 1998-2000 Italian National Health Plan (which is also included in the present report) that has been conceived as a true Solidarity Agreement for Health-. Such an agreement commits institutions, professionals, citizens and their organizations, the research community and industries to taking on common responsibilities for achieving the health objectives agreed upon.

We would like to share the spirit of this agreement with the other countries of Europe looking forward to the new century.

file://Q:\-COMMON\TRANSPRT\From%20Nicoletta%20to%20Dany\Ehi\itahfa21\fore...w 07-Jan-02 FOREWORD

J.E. Asvall WHO Regional Director for Europe

As we stand on the brink of the twenty-first century, we have a strong obligation to take action to improve the health of the 870 million people of the Region. The Health21 policy approved by the WHO Regional Committee for Europe in September 1998 provides the framework for accepting that challenge by applying the best strategies that have emerged from Europe's collective experience during the past ten to fifteen years.

It is not a vision beyond our grasp it can be done. Experience has shown that countries with vastly differing political, social, economic and cultural conditions can develop and implement health for all policies designed to put health high on the agenda and when they do, they stand to gain from a fundamental change for the better. The major challenge for the 51 Member States of the European Region is to use the Health21 policy as an inspirational guide to update, as necessary, their own policies and targets. The commitments taken by the European member countries at the Third Ministerial Conference on Health and Environment held in London 16-18 June 1999 are an excellent example of what can be achieved when scientific evidence, innovative thinking and political leadership are put together within a coherent health policy framework to achieve common goals.

The Health in Italy in the 21st century- report, prepared by the Italian Government with the assistance of the Rome Office of the WHO European Centre for Environment and Health, is an important step towards the implementation of the Health21 policy and principles. It underlines the achievements of the past years, relates them with the Health21 goals, and sets the direction for future health policy developments as outlined in the 1998-2000 Italian National Health Plan. The document provides scientifically sound data against which future assessments can be measured.

I would like to use this opportunity to commend the Italian government for undertaking this work which transforms the vision of Health21 into a practical and sustainable reality. This, I am sure, will encourage other Member States to do the same. ACKNOWLEDGEMENTS

The Report Health in Italy in the 21st Century has been produced jointly by the Ministry of Health of Italy and the WHO European Centre for Environment and Health (WHO/ECEH) thanks to the work of two teams (Ministry of Health and WHO/ECEH) and to the additional support and valuable contributions of a large number of other organizations and experts.

Teams for the preparation of the Report Health in Italy in the 21st Century

Overall coordination and supervision: Roberto Bertollini (WHO/ECEH) and Vittorio Silano (Ministry of Health, Repubblica Italiana)

Scientific/technical/editorial work:

WHO/ECEH Team Nicoletta Di Tanno, Michele Faberi, Manuela Gallitto, Daniela Giannuzzo, Philip Gorman, Lucilla Magherini, Maria Teresa Marchetti, Francesco Mitis, Candida Sansone, Manuela Zingales.

Ministry of Health of Italy Team Francesco Cicogna, Gianfranco Costanzo, Gaetano Della Gatta, Katia Demofonti, Angelo De Siena, Luisa Gabrielli, Stefano Moriconi, Fabiana Leoni, Alessandra Pappagallo.

Several Department and Service Directors of the Ministry of Health of Italy (Claudio Calvaruso - Director General, Studies and Documentation; Nerina Dirindin - Director General, Health Planning; Fabrizio Oleari - Director General, Prevention, and Giovanni Zotta - Director General, Institutions Control) have kindly provided highly appreciated advice, data and information, when reviewing the Report. Similary, enlightening contributions have been received by Antonio Moccaldi, Director General, National Institute for Prevention and Safety at the Workplace, and Francesco Taroni, Director General, National Agency for Regional Health Services as well as by members of their staff. Information, advice, data and support was provided throughout the preparation of this report by the National Institute of Health (ISS). Particular thanks go to Giuseppe Benagiano, Director, National Institute of Health, and to many of his staff: Riccardo Capocaccia, Marco De Sanctis, Massimo Giuliani, Donato Greco, Alfonso Mele, Giovanni Rezza, Stefania Salmaso and Barbara Suligoi.

The Italian National Statistics Institute generously shared information and data. Thanks to Viviana Egidi, Director for Population and Territory, and her co-workers Giovanna Boccuzzo and Vittoria Buratta, for the collaboration.

Claudia Galassi, CDS Bologna, gave a significant input and scientific contribution to the report, and Giuseppe Costa, Director of the Public Health Laboratory, ASL 5 Piemonte Region, has made available his pioneering experience and work on inequalities and health. Riccardo Poli, member of the Higher Health Council of Italy, has contributed the Chapter on "Bioethics in human health"; Edoardo Missoni, Ministry of Foreign Affairs, the Section on Italian Development Co-operation and Raffaele Tamiozzo, Head of the Legal Office, Ministry of Health, the Chapter on "Italian Health Service Reform".

Eva Buiatti, CSPO, Florence; Francesco Forastiere, Lazio Region Epidemiology Unit; Colin Soskolne, University of Alberta (Canada) and Benedetto Terracini, University of Turin, have reviewed the first draft of the text and provided very useful comments and suggestions.

A number of other experts, including Piero Borgia and Marina Davoli, Lazio Region Epidemiology Unit; Ernesto Caffo, Telefono Azzurro; Bruno Dalla Piccola, Second University of Rome (Tor Vergata); Anna Ferro- Luzzi and Luisa Pizzoferrato, National Institute of Nutrition; Luigi Greco, University of Naples; Paola Pula Leggio, Ministry of Health; Pierpaolo Mastroiacovo, Catholic University of Rome and Giorgio Tamburlini, Istituto per l'Infanzia Burlo Garofalo, Trieste, have provided valuable data, information and advice in their areas of expertise. TABLE OF CONTENTS

FOREWORD by Rosy Bindi (Minister of Health of Italy)

FOREWORD by J. E. Asvall (WHO Regional Director for Europe)

ACKNOWLEDGEMENTS

PART I Achievements and challenges in the European context

I - International solidarity for health and development II - Italy as an ageing society III - A healthy start in life IV - Non-communicable diseases V - Communicable diseases VI - External causes of mortality and disability VII - Health determinants: nutrition, lifestyle, physical environment and human settlements VIII - Equity in health IX - Bioethics in human health X - The Italian National Health Service XI - Human resources and research for health

PART II The way forward

XII - Nation wide solidarity agreement XIII - Priority objectives for health XIV - Change-promoting policies and strategies XV - Italian health service reform XVI - Methods and data sources

ANNEXES

REFERENCES CHAPTER I

INTERNATIONAL SOLIDARITY FOR HEALTH AND DEVELOPMENT

CONTENTS

1. INEQUALITIES IN HEALTH WORLD-WIDE ...... 4

2. INEQUALITIES IN HEALTH IN THE WHO EUROPEAN REGION...... 5

3. ITALIAN GOVERNMENT CONTRIBUTIONS TO INTERNATIONAL SOLIDARITY ...... 8 3.1 International Organizations...... 8 3.2 European Union ...... 10 3.3 Italian development co-operation ...... 11

4. CITIZEN DIRECT PARTICIPATION TO HUMANITARIAN ASSISTANCE ...... 14 4 - International solidarity for health and development

1. INEQUALITIES IN HEALTH WORLD- This major economic gap and the consequent WIDE increase in prevalent poverty is reflected in the distribution and time trend of major health indi- A recent review by the United Nations Confer- cators. Inequalities in life expectancy at birth and ence on Trade and Development (UNCTAD) mortality rates1 are very significant world-wide suggests that, since the early 1980s, the global and indeed much more significant than in the economy has been experiencing rising inequal- European Region (WHO, 1999a). Many countries ities (Table I.1) and that income gaps among are facing several problems from infectious dis- countries have continued to widen. In 1965, eases (such as HIV/AIDS), while chronic non com- the average per capita income of the G7 indus- municable diseases, such as heart disease, cancer, trialised countries was 20 times that of the diabetes and other “lifestyle” related-conditions world’s poorest seven countries; by 1995, it was (see also Chapter II) are on the increase. about 50 times greater. Although a number of Refugees represent an especially vulnerable developing countries have been growing faster population, and their number increased than the developed market economies, growth markedly world-wide during 1985-1990, from rates have not been fast enough to narrow the 10.5 million to 14.9 million, accounting for absolute per capita income gap. One major 12.4% of the world’s migrant stock in 1990. By constraint inhibiting further economic growth early 1996, the total number of refugees stood and international macroeconomic stability has at 13.2 million. Recent crises in different parts been the debt burden of the developing coun- of the world, including Europe, are again tries (WHO, 1998a). responsible for increase in this number.

Table I.1: Growth of GDP and GDP per capitaa.

GROWTH OF GDP GDP PER CAPITA (ANNUAL PERCENTAGE CHANGE) (USD)

1981-1990 1991-1996 1980 1996 1997

World 3.1 3.3 4 883 5 966 6 123 Developed market economies 2.8 1.7 16 547 21 995 22 497 Economies in transitionb 2.0 – 6.4 5 464 4 012 4 062 Developing countries 3.8 5.8 2 102 3 147 3 282 of which LDCsc 2.4 3.5 1 097 1 132 1 159

a On the basis of purchasing power parity. b Including the former German Democratic Republic until 1990. c Least Developed Countries.

Source: WHO, 1998a.

1 Life Expectancy: the average number of years an individual of a given age is expected to live if current mortality rates continue to apply. A statistical abstraction based on existing, age-specific death rates (Last J., 1988). Mortality rate: proportion of a population that dies during a specified period. It is obtained dividing the number of persons dying during the period by the size of the population, usually estimated as the mid-year population (Last J., 1988). International solidarity for health and development - 5

2. INEQUALITIES IN HEALTH IN THE WHO According to the UNDP Human Development EUROPEAN REGION Report (UNDP, 1997), a number of countries has seen a great economic decline in the past The WHO European Region includes some of decade. Poverty has spread and about 120 mil- the richest countries in the world as well as oth- lion people in Europe live below the poverty line ers which are extremely poor; a large, group of of 4 USD a day. countries is now less well-off than ten years The economic upheavals and the wars in the ago. In 1995, the per capita Gross Domestic Countries of Central and Eastern Europe Product in Europe (GDP) ranged from 943 USD (CCEE) and Newly Independent States (NIS) to over 34 004 USD (Figure I.1). during the 1990s have increased the health

Figure I.1: GDP per person, expressed at purchasing-power parity, in the WHO European Region+ - 1995. Countries

US Dollars

Source: WHO, 1999c. 6 - International solidarity for health and development

status gap between countries in the Region, both sexes from 73.1 years in 1991 to 72.4 in as reflected in the wide range of variations 1994. Female life expectancy is higher in all in many basic health indicators (WHO, countries: on average, it is 76.68 years as com- 1999b). pared to 68.07 for males (Figure I.2). Total mortality rates and life expectancy are Long-term trends show a continuous improve- two powerful indicators of the overall health ment of life expectancy in Western Europe status of the European population and are (although the improvement rate varies signifi- useful descriptors of the inequalities among cantly among individual countries). Figures indi- countries. cate a stabilisation in the CCEE and a decrease The average life expectancy in the WHO Euro- in the NIS. In this situation, the gap in life pean Region has declined for the first time expectancy between Eastern and Western since the World War II; starting from 1990, the European countries that started about three average life expectancy in the NIS decreased for decades ago is steadily growing (Figure I.3).

Figure I.2: Life expectancy at birth in the WHO European Region for females and males – 1994. Countries

Life expectancy (yrs)

Source: WHO, 1999c. International solidarity for health and development - 7

Figure I.3: Life Expectancy at birth for both sexes combined in subregional groups of countries in the WHO European Region. Time trend. Life expectancy (yrs)

Calendar year Source: WHO, 1999c.

Estimates of life expectancy in Europe for TARGET 1 - HEALTH21 1997 show that the difference between the By the year 2020, the present gap in third of those countries with the highest health status between Member States (average 78.2 years) and the third with the of the European Region should be lowest (average 68.7 years) was 9.45 years reduced by at least one third. (WHO, 1998a). In order to meet the Health 21 target and assuming the 1997 values of In particular: the highest tertile as a reference, this gap 1.1 the gap in life expectancy between should be reduced to 6.61 years by 2020. Life the third of European countries expectancy projections for the year 2025 with the highest and the third of indicate that the highest tertile of countries countries with the lowest life will move to an average of 80.2 years and the expectancy levels should be lowest to 74.3 years (WHO, 1998a). Under reduced by at least 30%; this hypothesis, the gap between the highest 1.2 the range of values for major indi- and the lowest tertile will be 6.5 years, thus cators of morbidity, disability and making the above-mentioned target achiev- mortality among groups of coun- able. tries should be reduced through The range of differences of major indicators of accelerated improvement of the mortality and morbidity in the European coun- situation in those that are disad- tries mirrors the trend observed for total mor- vantaged. tality (WHO, 1999b). 8 - International solidarity for health and development

3. ITALIAN GOVERNMENT CONTRIBUTIONS operation in health and social development TO INTERNATIONAL SOLIDARITY with many developing countries.

In order to promote global health, poverty in 3.1 International Organizations the poorest countries of the world, as well as the pockets of poverty which exist within devel- Italy actively supports large numbers of UN Pro- oped countries, should be significantly reduced. grammes, subsidiary Bodies, specialised Agencies Policies directed at improving health and ensur- and related autonomous Organizations. In this ing equity are the keys to economic growth and respect, the UN System is regarded by Italy as an poverty reduction. Sharing health and medical essential component of its foreign policy, particu- knowledge, expertise and experience on a larly in the area of peacekeeping, humanitarian global scale is another powerful way of pro- assistance and solidarity for health promotion and moting equity in health. Humanitarian relief social development. must be provided when needed. Italy is currently the fifth largest contributor to the Industrialized countries, such as Italy, have a UN regular budget, allocating in 1998 56.9 mil- vital role to play in helping to solve global lion USD, roughly corresponding to 5.4% of the health problems. In the context of the 1998 total UN budget. World Health Declaration and its commitment An additional contribution of approximately 64 to the highest attainable level of health for all, million USD has been provided by Italy through existing differences in economic, social and the participation in UN peace keeping operations health conditions throughout the world repre- in countries such as Lebanon, Kuwait, Ex- Yugoslavia and Albania. sent a serious threat upon human rights. Additional funding is provided by the Italian Gov- Italy considers health to be a fundamental ernment to the UN System through regular bud- human right, and the progressive growth of get contributions to the specialised Agencies and large inequalities in health conditions and other Organizations (for some figures see Table quality of life within and among different I.2) as well as to the UN International Court of Jus- areas of the world to be unacceptable. The tice (5.2 million USD per year). promotion of equity in health is, therefore, a In addition to regular contributions, in 1998 priority of the Italian Government not only at the Italian Government allocated about 80 national level, but also at European level and million USD as voluntary contributions to UN indeed world-wide. Programmes, Organizations and Funds active Italy is an active member of the United Nations in the areas of humanitarian assistance, eco- and its subsidiary and specialised Bodies, as well nomic development and health promotion as a member of several other intergovernmen- (see Table I.3 for details). Some of these also tal Organizations such as the Council of Europe benefit from earmarked funds to support spe- (CE) and the Organization for Economic Coop- cific projects in developing countries. eration and Development (OECD). The efforts In this framework, Italy considers the support it of Italy to alleviate the suffering of the poor and gives to WHO as one of its priorities, and sig- promote equity in health, in addition to social nificantly contributes to its “extrabudgetary and economic developments, are also directed funds”. One major Division of the WHO Euro- by the European Union through funding allo- pean Centre for Environment and Health is cated for international co-operation and based in Rome and many WHO Collaborating humanitarian assistance. Lastly, Italy has also Centres2 operate in Italy, often supported by the established significant levels of bilateral co- competent Region or Self-governed3 Provincial

2 A WHO Collaborating Centre is defined as an institution designated by the Director General to form part of an international collaborative network carrying out activities in support of the Organization’s programme at all levels. This definition does not include all other Institutions collaborating with WHO under other arrangements. 3 Synonym of "autonomous" also used throughout the present report. International solidarity for health and development - 9

Table I.2: Italian Regular Budget Contributions to UN Specialised Agencies – 1998.

UN AGENCY CONTRIBUTION (MILLION USD)

IARC - (International Agency for Research on Cancer) 1.3 ILO - (International Labour Organization) 12.0 FAO - (Food and Agriculture Organization) 17.9 WHO - (World Health Organization) 21.3

Authorities (Annex 1). It should also be men- Similar considerations apply to Italy’s role in the tioned that these provide support to specific CE, an intergovernmental Organization whose WHO programmes (both HQ and EURO). Italy is main objectives in the social field include the also an important contributor to several other protection of human rights of all populations International Organizations. and minority groups as well as the search for Italy is a founder country of the OECD and partic- solutions to social problems, such as xenopho- ipates in the initiatives of this Organization to pro- bia, intolerance, environment protection, mote social welfare by co-ordinating the econom- bioethics, AIDS and drug abuse. Italy is one of ic policies of Member States and to stimulate and the founder countries of the CE, which, at pre- harmonize Member States efforts towards devel- sent, includes 41 nations Europe-wide. The oping countries. Of all the current 29 member main activities of the CE supported by Italy countries, it is the fifth largest financial contribu- include health issues such as: tor after the USA, Japan, Germany and France. In • European Pharmacopoeia. 1997, the total Italian contribution to the OECD • Blood Transfusion: ethics and safety. was approximately 14 million USD. • Organ transplants.

Table I.3. Voluntary contributions of Italy to UN Programmes and Organizations – 1998.

UN COMPONENT CONTRIBUTION (MILLION USD)

ECEH (WHO European Centre for Environment and Health) 1.5 FAO (Food and Agricultural Organization) 8.6 CRC (International Committee of the Red Cross) 3.7 IFAD (International Fund for Agricultural Development) 1.1 ILO (International Labour Organization) 4.8 UN/DESA (Department for Development Support) 5.7 UNDCP (UN Drugs Control Programme) 8.6 UNDP (UN Development Programme) 10.8 UNETPSA (UN Educational and Training Programme for Southern Africa) 1.1 UNFPA (UN Population Fund) 1.4 UNHCR (UN High Commissioner for Refugees) 6.9 UNICEF (UN International Children Fund) 6.8 UNIDO (UN Industrial Development Organization) 2.3 UNV (UN Volunteers) 0.6 WFP (World Food Programme) 4.6 WHO (World Health Organization) 3.7 10 - International solidarity for health and development

• Cooperation against drug dependence (Pompi- up in Brussels), agricultural and rural development dou Group). (e.g. an ad hoc technical Centre has been set up • AIDS. in Washington), as well as commercial and finan- • Youth-related problems. cial cooperations. • Human health care services. In 1998, in compliance with article 255 of the • Consumer health protection. 4th Lomé Convention, the EU adopted two pro- The Italian financial contribution to the CE in grammes in favour of repatriated refugees and 1998 was about 21.6 million USD. evacuees from Liberia and Guinea, with a budget of about 2.4 million USD. Since this conven- 3.2 European Union tion entered into force, 75 similar programmes have been carried out with a global expenditure Italy is a founder country of the European Eco- of about 82 million USD. In addition, under the nomic Community (EEC) which, in 1993, became provisions of article 133 of the Amsterdam the European Union (EU). Treaty, the Council has extended the System of The European Union has a very active role not General Preferences to all countries in need, only in ensuring a high level of protection of regardless of whether they signed the Lomè health, but also in carrying out interventions in Convention or not. supporting the economic and social development In 1998, EU health cooperation with developing of non-EU members, as well as in providing countries received special attention and was allo- humanitarian and technical assistance. The fight cated a budget of about 248 million USD for pri- against poverty is an essential component of EU ority sectors such as: cooperation for development; in 1998, the Euro- • disease prevention; pean Parliament, in fact, expressed support for a • human resource development; debt reduction in favour of countries in which • health system organization; poverty is a major issue. • coordination with other donors. Proof of the commitment of the European Union In the same year, the total amount of food prod- in this area lies in its budget of 200 million USD ucts donated by the EU to the World Food Pro- allocated, for the years 2000-2006, to the gramme (WFP) reached approximately 93 million enlargement of the Union to include Central and USD. Resources allocated in the EU 1998 budget Eastern Europe. for food aid and food safety in favour of devel- The European Union has signed cooperation oping countries amounted to around 495 million agreements with several Mediterranean and Mid- USD, almost 385 million of which were used to dle-Eastern countries (i.e. Algeria, Morocco, purchase food products and to support food Tunisia, Egypt, Jordan, Syrian Arab Republic, safety, and 110 million USD for logistic expendi- Lebanon and Israel), and these have been in force tures. since 1978. In 1998, the EU also allocated 26.5 million USD The economic cooperation and technical assis- to promote investments of mutual interest and to tance provided by the European Union has also establish joint enterprises with non-EU country been extended to African (A), Caribbean (C) and entrepreneurs (EC Investment Partners Instru- Pacific (P) countries through the Lomé Conven- ment). tion. The fourth ACP-EEC Convention was signed Lastly, in 1998, within the framework of Regula- at Lomé (Togo) by the EEC and its Member States, tion (CE) 2258/96 concerning rehabilitation and as well as by 69 ACP countries. It has a duration reconstruction in developing countries, the EU of 10 years, starting from 1 March 1990, and a invested some 68 million USD, 49 of which were financial protocol which is renewable every 5 for ACP countries. years. This Convention provides for industrial European Community humanitarian assis- cooperation (e.g. an ad hoc Centre has been set tance is provided, in particular, by the Euro- International solidarity for health and development - 11

pean Community Humanitarian Office budget formation, it is also one of the main con- (ECHO). In 1998, the European Commission tributors to EU activities. appropriated through ECHO the sum of 547 million USD for humanitarian relief, mostly 3.3 Italian development cooperation4 consisting of interventions for health, food, rehabilitation and reconstruction (Table I.4). In A process to re-define Italian strategies for devel- financial terms; Bosnia and Herzegovina and opment co-operation in health was undertaken in the African Region of Great Lakes were the 1998, taking into account the modified interna- main areas of EU humanitarian intervention in tional scenario and the experience gained in the 1998. field, in order to achieve a more effective synergy If this budget is considered together with the both with other international partners and with resources provided by each Member State, it the Italian National Health System (INHS). becomes clear that in 1998 the European Union In addition to humanitarian activities and was the most important donor for humanitari- response to natural catastrophes, the Italian co- an relief world-wide. operation managed more than 100 health pro- In 1999, the European Union reacted very grammes in 47 countries in 1998, with a global promptly to the crisis in Kosovo both through disbursement of around 37 million USD. ECHO and individual emergency plans. Expect- Bilateral, multilateral and multi-bilateral net dis- ed support from ECHO in 1999 is in the order bursements for health in the triennium 1996- of 184 million USD. 1998 (Table I.5) and distribution by world Regions The financial involvement of the European in 1998 (Table I.6) are shown below. Up to June Union in all of the above-mentioned activities 1999, Italy reacted to the Kosovo crisis by appro- constitutes a considerable part of the yearly priating about 60 million USD for assisting budget that consists of: refugees, hosting families and other interven- • customs duties; tions; an additional budget of about 40 million • agricultural drawings collected on products USD has been appropriated for the second stage imported from third countries; of the intervention in Albania. • a fraction of the VAT applied on goods and In order to carry out the above-mentioned activi- services of the entire Union; ties, the Italian Ministry of Foreign Affairs works in • a fraction of the GDP of each country. close liaison with the Italian Ministry of Health and Since Italy is one of the largest EU countries, on with a number of other public Institutions, such as the basis of the above-mentioned mechanisms of the National Institute of Health, the National Insti-

Table I.4: Humanitarian Assistance Provided by ECHO in various Geographical Areas of the World.

GEOGRAPHICAL AREA CONTRIBUTION (MILLION USD) WHO European Region 166.0 Mediterranean Countries and Middle East 44.3 Asia 63.0 Latin America 49.9 ACP Countries 160.8

4 According to the 1998 OECD Report on Development Cooperation, the total disbursement in 1997 was equal to about 1 300 million USD which was devoted to a number of activities including education, health and population, production, debt relief, social and economic infrastructures and emergency aids. 12 - International solidarity for health and development

tute of Nutrition, Universities, the Health Care ilar way, the Italian cooperation co-ordinated the Institutes of a Scientific Character (IRCCSs), the health planning of and technical assistance to the Local Health Authorities and Local Health Agen- Palestinian Ministry of Health in 1998. A similar cies, as well as a significant number of Non-Gov- approach has been followed in Mozambique, in ernmental Organizations (NGOs). Eritrea and in Angola. Italy is the main donor country in Uganda, where it also promotes the 3.3.1 Support to National Health Systems integration between Governmental and private “no profit” services, with the aim to improve Support to National Health Systems and their health care quality and accessibility, as well as to development is the basic strategy of the Italian co- optimise the available resources. operation with developing countries in the health sector. In this framework, Italy recognizes the 3.3.2 Support to Local Health Systems need for a strong coordination among donors and International Organizations (EU, WHO, Interventions in the health sector are mostly tar- UNICEF and other UN organizations, World Bank geted to administratively and geographically well and other bilateral agencies) in supporting defined areas, such as districts, departments and National Institutions. In Ethiopia, for example, Italy provinces. These initiatives aim to promote decen- contributed to launch the National Health System tralisation and implement at local level the Nation- Development Programme on the basis of a sectoral Health Plans, with the objective of improving the wide approach which overcomes the traditional quality and availability of health care, as well as project-based approach, promoting direct support facilitating community participation in the promo- of national policies and coordinated investment tion and management of health care systems. plans amongst different donor countries. In a sim- Good examples of this approach can be found in

Table I.5: Italian Co-operation to Development in the health sector: net disbursements by channel - 1996-1998.

CHANNEL 1996 1997 1998 (MILLION USD) (MILLION USD) (MILLION USD) Bilateral 38.6 41.0 25.9 Multilateral 8.6 2.4 4.3 Multi-bilateral 15.5 3.4 6.9 TOTAL 62.7 46.8 37.1

Source: Italian Ministry of Foreign Affairs, 1999.

Table I.6: Italian Cooperation to Development in the health sector: net disbursements by world Region - 1998.

WORLD REGION (MILLION USD) Central Africa 3.7 Southern Africa 11.8 Mediterranean and Middle East 4.1 Latin America 2.5 Asia 7.1 Southern and Eastern Europe 5.2 Not assigned 2.7 TOTAL 37.1

Source: Italian Ministry of Foreign Affairs, 1999. International solidarity for health and development - 13

Angola, Uganda, Mozambique, Zimbabwe, organization of second level health care services Ethiopia, Egypt, Bolivia, Jamaica and China. and to the implementation of computerized management of medical equipment, supply and main- 3.3.3 Development of information systems and tenance. Finally, in Morocco, Italy provided finan- epidemiological surveillance cial support to the “Pasteur Institute” in Tangiers for parasitic infection research. In Albania, Angola, Mozambique, Palestine and Swaziland, Italy is helping the building up specific 3.3.6 Primary health care information systems whose role is essential to health planning, in addition to running public Primary health care remains for the Italian co- health and environmental laboratories. Similar operation an essential integrated strategy. projects are currently in progress in some The main areas of intervention are: provinces of Zimbabwe and are also planned in • Control of communicable diseases: Italy supports South Africa in 1999, where Italy supports the the inclusion in National Health Plans and local sys- development and implementation of a geograph- tems of integrated activities for, among others, the ical information network. prevention and control of malaria, tuberculosis, leprosy and AIDS. Through WHO, the Italian 3.3.4 Promotion of National Pharmaceutical Sys- Cooperation takes part in poliomyelitis and dra- tems and essential drugs cunculiasis infection eradication campaigns in Africa. In Uganda, Ethiopia, Eritrea, Pakistan and Actions for up-grading and strengthening the the Philippines the fight against the resurgence of National Pharmaceutical Systems have been car- tuberculosis and its association with AIDS has ried out mainly in collaboration with WHO. Bilat- been supported in compliance with WHO strate- eral actions aimed at ensuring the local produc- gies. As far as malaria is concerned, Italy is sup- tion and distribution of essential drugs as well as porting activities mainly through several Italian supporting local stock management are under research Institutes working in African countries way in Morocco and Burkina Faso. (e.g. Burkina Faso, Madagascar, Ethiopia and Eritrea). In 1998, the scientific cooperation agree- 3.3.5 Promotion of health infrastructure and sus- ment signed by Italy and the USA included in its tainable biomedical technologies agenda the fight against malaria in South-Saharan Africa. Furthermore, Italy endorsed the recom- Refurbishing existing health infrastructure and mendation to include the strengthening of global adapting them to users’ needs has been the goal parasitic infection control in the 1998 G8 agenda. of the Italian cooperation’s activity in Lebanon, • Family and Reproductive health: gender Uganda, Egypt and Syria. The Italian co-operation approach. Italy collaborates with WHO in defining gives great importance to the environmental and and implementing strategies and policies in the cultural impact as well as its technological appro- field of Reproductive health and Nutrition. Specif- priateness. In Bolivia, for example, it chose to ic activities in this area have been organically inte- refurbish an old hospital rather than build a brand grated in primary health care actions in Africa, new one. New health care structures have been Asia and Latin America. Women’s health promo- built in some countries (e.g. Eritrea and Palestine). tion, with special regard to the most vulnerable A programme aimed at updating available health groups (e.g. adolescents and single parent fami- technologies and organising the National mainte- lies) is particularly relevant in these programmes. nance system was started in Macedonia in 1998. • Disability prevention and rehabilitation. In A similar Programme has been in place for many Mozambique, Italy supports the de-institutionali- years in Mozambique. In Tunisia and Algeria, the sation and socio-economic integration of mental- Italian co-operation has contributed to the rely handicapped people, by also providing techni- 14 - International solidarity for health and development

cal assistance, at national level, in the develop- and Madagascar, local applied research and ment of sectoral policies. In Uganda and Eritrea, capacity building. the Italian co-operation supports the establishment of orthopaedic workshops and the training 3.3.9 Other activities of physical therapists. In India, therapy and rehabilitation for people with spinal injuries, in addi- Other institutional activities are carried out by the tion to community based experiences, are being Italian Ministry of Health through specific agree- provided through the Italian cooperation. ments usually negotiated with non-EU countries and countries currently in the process of joining the 3.3.7 Health promotion in the field of multisec- European Union. These agreements, as a rule, toral programmes make provision for the organization of training courses for health professionals, the establishment Often, the Italian co-operation promotes health of scientific exchanges, health systems information actions within the framework of wider multi-sec- exchanges, as well as facilitating of health co-oper- tor initiatives. This is the case of the Local Human ation actions by means of technical equipment Development Programmes in Mozambique, Cen- delivery and support to hospital structures. Italy also tral America, Cuba, the Dominican Republic and co-operates with some of these countries through Tunisia, as well as of the “Atlas Project” in Bosnia, the EU Programme “PHARE” for the legislation implemented by UNOPS with a significant WHO alignment to the Community “acquis”, particularly input, on the basis of Italian financial support. in the field of phytosanitary and veterinary health, Similarly, in the context of European initiatives for environmental pollution, the safeguarding of biodi- Somalia, Italy supports several health actions with versity and health and safety at work. the participation of Italian NGOs. In Somalia, Lastly, mention should be made of what is Eritrea and Ethiopia, Italy participates with other termed “decentralized cooperation” carried out countries in promoting the IGAD Forum: in this by several Italian Regions, Autonomous Provinces context Italy contributes, through WHO, to health and local Institutions, mostly with humanitarian actions to benefit nomadic and border popula- objectives. This approach aims to strengthen tions. In some cases, health activities play a rele- cooperation and exchange among the local com- vant role in the context of more complex interna- munities of donor and recipient countries, thus tional initiatives. In the peace process in the Mid- mobilizing additional substantial resources for dle East, Italy spearheads the public health initia- development policies. This cooperation has also tive of the Refugees Working Group. made it possible for a number of sick children and adults to undergo advanced medical treat- 3.3.8 Development of human resources ments in Italian hospitals.

Training is an integral component of all the Ital- 4. CITIZEN DIRECT PARTICIPATION TO ian co-operation initiatives. It is delivered local- HUMANITARIAN ASSISTANCE ly and includes the updating and up-grading of local capacities in the framework of health sys- Innumerable cases and interventions witness the tems reforms. Residential training courses are generosity of Italian citizens and their NGOs, as also organised in Italy, with fellowships well as their invaluable contributions to interna- enabling the participation of developing coun- tional solidarity. A very recent example of this irre- tries’ health personnel in training programmes placeable role is provided by the voluntary contri- within Italian health Institutions. In some coun- butions in 1999 of more than 50 million USD to the tries (such as Jordan, Mozambique, Eritrea and “Rainbow Mission”, organized by the Italian Gov- Egypt), Italy supports local training Institutions ernment, and of about 9 million USD to UNHCR to and, in some other cases, such as Burkina Faso alleviate the Kosovo crisis. CHAPTER II

ITALY AS AN AGEING SOCIETY

CONTENTS

1. AGE STRUCTURE OF THE ITALIAN POPULATION...... 16 1.1 Present situation ...... 16 1.2 Future trends ...... 16

2 FACTORS UNDERLYING AGEING...... 17 2.1 Increased longevity and disability-free ageing...... 17 2.2 Reduced natality ...... 21 16 - Italy as an ageing Society

1. AGE STRUCTURE OF THE ITALIAN POPU- "elderly index", Italy is the "oldest" country in LATION Europe (Table II.1). In Italy, there are marked geographical differ- The proportion of the Italian population aged ences concerning the longevity of the popula- over 65 years is increasing very quickly and will tion: in the North, the elderly index is twice as continue to do so in the future. Although this much as that of the South (Table II.2). The Lig- development is undoubtedly an indicator of uria Region has the highest percentage of successful health and social policies in Italy, it elderly people. also poses new challenges. 1.2 Future trends 1.1 Present situation In Italy, the percentage of population aged 65 In the WHO European Region, Italy has the years or above was 9.5% in 1961 compared to smallest proportion of people aged 14 years or 16.8% in 1996. Among people over 65 years, less (Figure II.1) and is second only to Sweden there is a greater and progressively increasing as regards the proportion of people aged 65 percentage of women, i.e. from 57.7% in 1961 years or more (Figure II.2). According to the to 60.0% in 1996.

Figure II.1: Population aged 0-14 in the WHO European Region - 1994. Countries

Percentage

Source: WHO, 1999c. Italy as an ageing Society - 17

Figure II.2: Population aged 65 years or more in the WHO European Region - 1995. Countries

Percentage Source: WHO, 1999c.

A highly significant increase in the proportion 2. FACTORS UNDERLYING AGEING of people over 65 years is expected to occur within the next 20 years: the most rapidly The ageing of the Italian population results growing population in most countries will be from two main factors: increased longevity and those aged 80 years and above. At the end of reduced natality. the next 30 years, the average European proportion of people over 80 years, calculated as a 2.1 Increased longevity and disability-free share of the over-65 population, will increase ageing from 22% to over 30%. Over the next 50 years the estimates of the proportion of population A considerable increase in life expectancy at aged between 64 and 85 years and of that birth has been occurring both in Italy and in above 85 years in Italy are shown for women in the European Union since 1970. Data are Figure II.3a and for men in Figure II.3b (based shown in Figure II.4a for women and in Figure on ISTAT 1997a). II.4b for men. 18 - Italy as an ageing Society

Table II.1: Elderly population and index in some European countries - 1995.

COUNTRY POPULATION OVER 65 YEARS ELDERLY INDEXa) (%) (%)

Sweden 17.46 92.63 Italy 16.62 111.67 Norway 15.94 81.79 United Kingdom 15.74 81.18 Greece 15.58 92.46 Germany 15.47 95.26 France** 15.34 80.57 Belgium* 15.31 84.26 Spain 15.27 91.88 Denmark 15.26 87.90 Austria 15.14 86.32 Switzerland** 14.65 83.24 Portugal 14.56 81.84 Finland 14.21 74.67 Luxembourg 13.99 75.91 Netherlands 13.24 72.00 Ireland** 11.40 45.49 Iceland 11.22 45.85

* 1992 ** 1993. a) The elderly index is obtained by dividing the population aged 65 years or more by the population aged 0-14 years (per 100). Source: WHO, 1999c.

Similarly, life expectancy at 65 years in Italy has life expectancy data are only available in shown a progressively upward trend since 1970 Europe for a limited number of countries. An for both sexes (Figure II.5a and Figure II.5b): effective comparison of available data is made during the last ten years (1983-1993), life difficult by the different methodologies used expectancy at 65 years has increased by 2.3 for population survey (WHO, 1998b). In any years for women (+13.5%) and by 2 years for case, available data (Table II.3) suggest that men (+14,5%). disability-free life expectancy in Italy for both Improved longevity in Italy is mainly associated men and women is closer to crude life with decreased mortality from cardiovascular expectancy than in other countries. These diseases (CVDs) at all ages and lower premature data also suggest that the gap in life mortality for cancer (see Chapter IV). expectancy between women and men nar- Increased longevity is a much better achieve- rows when considering DFLE, i.e. from 3.9 to ment if it is accompanied by good health and 2 years at the age of 65. full autonomy. In order to take into account all the important factors, the concept of In a survey conducted in 1994, 1 874 000 peo- "Healthy” or “Disability-Free Life Expectancy" ple aged 65 years or more were found to be (DFLE) has been developed. However, healthy affected by disability, corresponding to a rate of Italy as an ageing Society - 19

Table II.2: Elderly population and index in Italy by Region1 - 1996.

REGION1 POPULATION OVER POPULATION OVER 65 YEARS (%) 85 YEARS (%) ELDERLY INDEX2

Piemonte 19.11 2.17 160.30 Valle d'Aosta 17.69 1.81 141.49 Lombardia 16.26 1.65 125.04 Trentino Alto Adige 16.01 1.82 101.58 Veneto 16.83 1.76 126.80 Friuli Venezia Giulia 20.47 2.50 184.07 Liguria 23.26 2.71 227.09 Emilia Romagna 21.27 2.33 196.64 Toscana 20.99 2.37 181.55 Umbria 17.31 2.06 137.10 Marche 20.24 2.12 154.41 Lazio 15.85 1.38 109.77 Abruzzo 18.36 1.83 119.23 Molise 18.98 2.10 119.01 Campania 12.42 0.99 60.95 Puglia 13.78 1.24 74.59 Basilicata 16.09 1.58 90.49 Calabria 14.84 1.44 77.47 Sicilia 14.84 1.26 78.07 Sardegna 13.84 1.44 85.73

NORTH 18.26 1.98 147.76 CENTRE 18.46 1.84 139.81 SOUTH 14.20 1.27 75.69 ITALY 16.82 1.69 113.24

1 In Italy, there are 19 Regions and two Autonomous Provinces (Trento and Bolzano) sometimes also reported as "Trentino Alto Adige". However, throughout this report the term "Region", particularly in Tables and Figures, also covers these two Self-Gov- erned or Autonomous Provinces. 2 See Table II.1 for details. Source: based on ISTAT, 1997a.

20.8%. In Table II.4, estimates of the total num- As expected, disability increases with age. In the ber of people affected by disability according to very elderly (>80 years of age) more than 47% of age and type of disability are reported; each people are reported to be affected by disability. individual may have one or more disabilities Another useful health indicator is self-percep- (ISTAT, 1997b). However, it should be noted tion of health. Data from a cross-sectional sur- that as only old people living at home were vey carried out by ISTAT (Figure II.6a) show that considered in this study, the proportion of old the proportion of people reporting their health people affected by disability may have been as "good" is reasonably high. Moreover, the underestimated. percentage of elderly population with self-per- 20 - Italy as an ageing Society

Figure II.3a: Population aged between 64 and 85 years or more in Italy Projection 2000-2050. Females. Percentage

Source: ISTAT, 1997a. Calendar year

Figure II.3b: Population aged between 64 and 85 years or more in Italy Projection 2000-2050. Males. Percentage

Calendar year Source: ISTAT, 1997a. Italy as an ageing Society - 21

Table II.3: Comparison of life expectancy (LE) and disability-free life expectancy (DFLE) in years at age 65 for selected countries in Western Europe.

MALES FEMALES LE DFLE LE DFLE

Finland*, 1986 13.4 4.3 17.4 5.6

France*, 1991 15.7 10.1 20.1 12.1

Netherlands*, 1990 14.4 9.0 19.0 8.0

United Kingdom*, 1992 14.5 7.9 18.3 9.5

Italy, 1991** 14.9 12.2 18.8 14.2

* Source: Robine and Romieu, 1997. ** Source: ISTAT, 1995.

ception of health as "good" has improved from woman during the most recent years, which 1993 to 1996 (ISTAT, 1998a) (Figure II.6b). is well below the replacement level of 2.1 (Figure II.7). 2.2 Reduced natality There are marked differences among the Italian regions: in Southern Italy, the fertility rate is high- Italy's birth rate is the lowest in Europe and er than in Northern and Central Italy (1.4 com- indeed the lowest in the world today. The pared to 1 and 1.1, respectively, in 1995) (Figure fertility rate began to decrease dramatically II.8). Time trends tend to stabilize and those of from the end of 1960s, until it reached a the Southern regions become more similar to the steady value of about 1.2 children per values observed in the rest of the country.

TARGET 5 - HEALTH21

By the year 2020, people over 65 should have the opportunity of enjoying their full health potential and playing an active social role.

In particular: 5.1 there should be an increase of at least 20% in life expectancy and in disability-free life expectancy at age 65 years. 5.2 there should be an increase of at least 50% in the proportion of people age 80 years enjoying a level of health in a home environment that permits them to maintain autonomy, self-esteem and their place in society. 22 - Italy as an ageing Society

Figure II.4a: Life expectancy at birth in EU countries. Females. Time trend. Life expectancy (yrs)

Calendar year Source: WHO, 1999c.

Figure II.4b: Life expectancy at birth in EU countries. Males. Time trend. Life expectancy (yrs)

Source: WHO, 1999c. Calendar year Italy as an ageing Society - 23

Figure II.5a: Life expectancy at 65 years in EU countries. Females. Time trend. Life expectancy (yrs)

Source: WHO, 1999c. Calendar year

Figure II.5b: Life expectancy at 65 years in EU countries. Males. Time trend. Life expectancy (yrs)

Source: WHO, 1999c. Calendar year 24 - Italy as an ageing Society

Table II.4: People affected by disabilities in Italy in 1994.

AGE CLASS POPULATION DISABLED PEOPLE NUMBER (THOUSANDS) OF DISABLE PER TYPE OF DISABILITY*

(YEARS) (THOUSANDS) NUMBER % OF THE BED CHAIR HOME FUNCTIONS MOVEMENTS SIGHT, (THOUSANDS) POPULATION SPEAKING, LISTENING

60-64 3 066 182 5.94 11 14 22 121 73 23 65-69 3 166 287 9.07 20 17 59 151 134 42 70-74 2 590 369 14.25 26 18 73 232 169 68 75-79 1 288 302 23.45 34 22 50 218 134 51 >80 1 946 916 47.07 96 87 227 732 429 183

* Includes more than once the same person if affected by different types of disabilities. Source: ISTAT, 1997b.

Figure II.6a: People perceiving their health as “good” in Italy, by sex and age group – 1996.

Source: ISTAT, 1998a. Italy as an ageing Society - 25

Figure II.6b: Population aged 65 years or more with self-perception of health as "good" in different areas of Italy - 1993 and 1996. Percentage

Source: ISTAT, 1998a.

Figure II.7: Fertility rate in EU countries - 1995. Countries

Average number of children per women of fertile age Source: WHO, 1999c. 26 - Italy as an ageing Society

Figure II.8: Fertility rate in Italy by regions - 1995. Regions

Source: ISTAT, 1997d. Average number of children per women of fertile age CHAPTER III

A HEALTHY START IN LIFE

CONTENTS

1. INTRODUCTION ...... 28

2. INFANT MORTALITY...... 28

3. CONGENITAL MALFORMATIONS...... 30

4. BIRTHWEIGHT...... 31

5. TEENAGE PREGNANCIES ...... 31 28 - A healthy start in life

1. INTRODUCTION physiological processes – even though they may go wrong at times - and should be regarded as A healthy start in life includes events such as such by health professionals. The better a birth, physical development, learning to walk mother’s education, health and nutrition, the and talk, acquiring basic social and health val- higher her socio-economic living standard and ues, discovering the environment and strength- the quality of health-related services she ening bonds to parents and people close to the receives, the greater the chance of a successful family. pregnancy. A healthy start in life is largely relat- A healthy birth establishes the basis for a ed to the lifestyles and parenthood skills of healthy life. Pregnancy and delivery are natural both parents.

TARGET 3 - HEALTH21

By the year 2020, all new-born babies, infant and pre-school children in the Region should have better health, thus ensuring a healthy start in life.

In particular: 3.1 all member states should ensure improvements in access to appropriate reproductive health, ante-natal, peri-natal and child health services. 3.2 the infant mortality rate should not exceed 20 per 1 000 live births in any country; countries with rates currently below 20 per 1 000 should strive to reach 10 or below. 3.3 countries with rates currently below 10 per 1 000 should increase the proportion of new born babies free from congenital disease or disability. 3.4 mortality and disability for accidents and violence in under 5 year-olds should be reduced by at least 50%.1 3.5 the proportion of children born weighing less than 2 500 g should be reduced by at least 20% and the differences between countries should be significantly reduced.

2. INFANT MORTALITY There are marked differences among the Italian regions (Table III.1); in some Southern regions Like most Western European countries, at the infant mortality rate in 1994 was still over 8 national level Italy has met the regional WHO per 1 000 live births, i.e. almost three times as Health for All (HFA) target of an Infant Mortali- much as that of the Region with the lowest ty Rate (IMR) below 10 per 1 000 live births. In rate. 1994, the Italian infant mortality rate was 6.4 From 1980 on, the IMR in Italy fell by more per 1 000 live births, a slightly higher value than than 50% (this represents one of the largest the average for EU countries of 6.18 per 1 000 improvements in Western Europe during this live births (Figure III.1). period) (Figure III.1); this decrease is still con-

1 See Chapter VI. A healthy start in life - 29

Figure III.1: Infant mortality rate per 1 000 in EU countries. Time trend. Deaths per 1 000 livebirths

Source: WHO, 1999c. Calendar year

Table III.1: Infant mortality in Italy by region – 1994.

ITALIAN REGION RATE (PER 1 000) Piemonte 5.2 Valle d’Aosta 4.9 Lombardia 5.0 Trentino Alto Adige 4.9 Veneto 4.9 Friuli Venezia Giulia 3.3 Liguria 5.7 Emilia Romagna 5.5 Toscana 5.7 Umbria 4.9 Marche 6.4 Lazio 5.6 Abruzzo 8.7 Molise 6.9 Campania 8.8 Puglia 7.6 Basilicata 7.1 Calabria 8.4 Sicilia 8.5 Sardegna 5.0

AVERAGE (ITALY) 6.4

Source: based on ISTAT 1997c. 30 - A healthy start in life

tinuing (Table III.2) although to a lesser Overall, compared to the distribution based on degree. 1980-1992 data, a decrease in the proportion of neural tube defects, corresponding to a real decrease in frequency, can be observed (EURO- 3. CONGENITAL MALFORMATIONS CAT, 1997). The prevalence rates of neural tube defects are two to three times higher in the UK Data on congenital malformations at birth are and Ireland, although they declined during the difficult to compare across countries because of last 15 years (from a mean of 40 to 10-15 per different definition, diagnosis and registration 10 000). The prevalence rate of neural tube practices. However, comparisons made using defects for the Tuscany registry in the period population-based registers from some areas of 1990-1994 is 6.6 per 10 000. Neural tube Italy participating in the European Registration defects rates are 4.6 per 10 000 in Emilia of Congenital Anomalies (EUROCAT) network Romagna and 6.1 per 10 000 in the North East indicate that rates in Italy are comparable to respectively, compared to the Toscana rate and other areas of Europe. within the range of variability of the overall For EU Member States, estimates are available EUROCAT rates. from the EUROCAT project and from registers However, an increase in cardiac defects, inter- participating in the International Clearinghouse nal uro-genital anomalies and chromosomal for Birth Defects Monitoring Systems (ICBDMS). anomalies was detected. This increase may be In Italy, a network of registers exists, and some explained by a more efficient, more frequent of them follow - at least partially - the EURO- and earlier performed prenatal diagnosis. Dif- CAT methodology. Some also participate in the ferences in the overall prevalence rate (1990- ICBDMS. 1994) of Down’s Syndrome (11.5 to 23.0 per The prevalence rates of all congenital anomalies, 10 000 in Europe, 13.3 per 10 000 in Tuscany neural tube defects and Down syndrome (per registry) are explained by different maternal age 10 000 births) observed in the 16 registers that distributions and different rules for access to strictly follow EUROCAT methodology, including prenatal diagnosis and to abortion (EUROCAT, the Tuscany registry, are shown in Table III.3. 1997). The total prevalence rate of congenital malfor- A further decrease in prevalence at birth of mation based on these 16 registers (1 418 126 congenital malformations is indeed possible births - live and still) is 227.1 per 10 000 births through a more extensive use of prenatal (including foetal deaths and induced abortions). counselling and prenatal diagnosis. However, Induced abortions represent an increasing part of the effectiveness of this process is jeopardised the sample, i.e. 14.8% of the birth defects cases by the limited knowledge of the causes of in 1994 (about 12% in the Tuscany registry). many birth defects.

Table III.2: Infant mortality in Italian areas (provisional data for 1996).

ITALIAN GEOGRAPHICAL AREA RATE (PER 1 000) North-West 4.7 North-East 4.8 Centre 5.6 South 7.4

Italy 6.0

Source: ISTAT, 1998a. A healthy start in life - 31

Table III.3: Prevalence rate (per 10 000 births) of all congenital anomalies, neural tube defects and Down’s syndrome in the 16 registers following EUROCAT methodology - 1990-1994.

REGISTRY ALL CONGENITAL NEURAL TUBE DOWN SYNDROME ANOMALIES DEFECTS

ALL CASES MATERNAL AGE MATERNAL AGE UNDER 30 YEARS OVER 35 YEARS

NUMBER RATE NUMBER RATE NUMBER RATE NUMBER RATE NUMBER RATE GLASGOW(UK) 1 659 272.3 97 15.9 105 17.2 44 11.2 36 61.6 BELFAST (UK) 1 267 98.8 128 10.0 162 12.6 53 6.5 71 49.4 GALWAY (IRL)* 259 199.9 19 14.7 33 25.5 4 6.8 22 78.8 DUBLIN (IRL)* 2 266 240.0 134 14.2 193 20.4 44 8.7 108 72.3 ODENSE (DK) 617 208.7 27 9.1 46 15.6 10 5.2 21 74.5 NORTHERN NETHERLANDS 2 135 219.4 110 11.3 115 11.8 30 5.6 39 37.0 ANTWERP (B) 835 252.5 33 10.0 38 11.5 16 7.3 9 35.7 HAINAULT-NAMUR (B) 1 763 270.1 73 11.2 96 14.7 36 7.9 37 76.6 PARIS (F) 6 604 360.8 224 12.2 513 28.0 96 11.2 304 81.7 STRASBOURG (F) 2 351 349.4 68 10.1 119 17.7 46 10.5 52 75.9 BOUCHES DU RHONE (F) 2 596 227.5 126 11.0 231 20.2 58 8.7 104 63.9 SWITZERLAND 4 825 162.3 167 5.6 353 11.9 114 6.6 127 39.8 TUSCANY (I) 1 978 216.2 60 6.6 122 13.3 29 6.5 61 40.3 BASQUE COUNTRY (E) 1 727 215.1 88 11.0 155 19.3 28 7.3 77 76.0 ASTURIAS (E) 804 218.8 51 13.9 52 14.2 15 6.8 24 58.4 MALTA * 520 198.7 24 9.2 54 20.6 8 5.2 34 93.6 Total 32 206 227.1 1 429 10.1 2 387 16.8 631 7.8 1126 61.2

* Pregnancy termination is not legal in Ireland and Malta. Source: EUROCAT, 1997.

4. BIRTHWEIGHT ing birth to a low birthweight baby for mothers with low educational level (elementary school) is Birthweight is related to social status and to 1.5 higher than for those mothers with a uni- other factors such as smoking. It is a marker for versity degree (Di Lallo et al., 1993). indices of deprivation and represents an accu- In order to meet the HEALTH21 target in 2020, mulated risk over generations. low birthweight prevalence should reach an Between 1990 an 1994, low birth weight rates overall value of 3.8% (3.3% for males and (<2 500 g) ranged in the EU between 4 (France, 4.2% for females). Ireland and Spain) and 7% (UK) (UNICEF, 1998). In Italy, the low birthweight rate in 1995 was 4.7% (4.1% in males and 5.3% in females: 5. TEENAGE PREGNANCIES ISTAT). The incidence of low birthweight over the last fifteen years did not change significant- The number of births to women aged 15-19 ly and did not show any increasing or decreas- years decreased gradually from 1980 onwards ing trend (Lazio Region Epidemiology Unit, OER, in almost all Western European countries 1998; WHO-ECEH, 1997). Association with (Council of Europe, 1995). The highest propor- social status as measured by maternal education tions in 1994 were observed in Portugal was also observed in Italy. The probability of giv- (7.83%) and the UK (6.38%). Italy has a low 32 - A healthy start in life

TARGET 4 – HEALTH21

By the year 2020, young people in the Region should be healthier and better able to fulfil their roles in the society.

In particular: 4.1. children and adolescents should have better life skills and the capacity to make healthy choices2. 4.2. mortality and disability from violence and accidents involving young people should be reduced by at least 50%3. 4.3. the proportion of young people engaging in harmful forms of behaviour such as drug, tobacco and alcohol consumption should be substantially reduced4. 4.4. the incidence of teenage pregnancies should be reduced by at least one third.

proportion of teenage pregnancies (2.25%) 819.1 per 1 000 live births, similar to those comparable to that observed in a number of observed in Finland, Germany and the UK (Fig- European countries such as Germany, Den- ure III.3). mark, Finland, Sweden and France (Figure III.2). Data from Italian regions for 1995 (Table III.5) Data concerning the Italian regions (Table III.4) show very marked differences, with ratios rang- show marked geographical differences. South- ing from 283.4 abortions in Sicilia to 3 131.3 in ern regions show higher percentages of teenage Liguria per 1 000 livebirths. This may reflect pregnancies compared to the Northern regions. either a tendency to differential acceptance of The highest percentage was reported in Sicilia voluntary abortion to reduce unwanted preg- (about 5% of all live births to mothers under 20 nancies among teenagers, or a different avail- years) and the lowest in Liguria (less than 1%). ability of services providing voluntary abortion Another relevant indicator is the number of in some Southern regions. The possibility that abortions performed on teenage-mothers. In part of these differences may be attributable to 1995, data from EU countries in which volun- illegal pregnancy termination should also be tary abortion data are available indicate that considered (Spinelli A., 1995). However, from the number of voluntary abortion per 1 000 live 1986 onwards, the abortion rate among births ranges from 90.1 in Greece to 1 863 in teenagers is quite stable in Italy (about 3 per Sweden (WHO, 1999c). In Italy, the rate was 1 000 teenage women) (ISTAT, 1997a).

2 See Chapter VI. 3 See Chapter VI. 4 See Chapter VII. A healthy start in life - 33

Figure III.2: Live births to mothers aged less than 20 years in EU countries – 1994. Countries

*1991 **1992 ***1993 Percentage of livebirths Source: WHO, 1999c.

Table III.4: Number and percentage of all livebirths to mothers aged under 18 and 20 years in Italy by region – 1995.

REGION MATERNAL AGE (YEARS) PERCENTAGE OF ALL LIVE PERCENTAGE OF ALL LIVE <18 <20 BIRTHS TO MOTHERS BIRTHS TO MOTHERS AGED UNDER 18 AGED UNDER 20

Piemonte 87 437 0.27 1.33 Valle d’Aosta 4 12 0.40 1.21 Lombardia 145 797 0.19 1.06 Trentino Alto Adige 26 143 0.27 1.47 Veneto 86 444 0.23 1.18 Friuli Venezia Giulia 12 95 0.14 1.14 Liguria 15 99 0.14 0.93 Emilia Romagna 79 395 0.29 1.44 Toscana 64 339 0.26 1.36 Umbria 15 66 0.24 1.08 Marche 21 128 0.18 1.11 Lazio 116 538 0.25 1.16 Abruzzo 22 149 0.20 1.36 Molise 6 46 0.21 1.59 Campania 592 2 261 0.83 3.18 Puglia 527 1 708 1.21 3.91 Basilicata 25 102 0.42 1.72 Calabria 131 624 0.62 2.95 Sicilia 877 2 851 1.53 4.97 Sardegna 112 444 0.77 3.06

Italy 2 962 11 678 0.57 2.25

Source: based on ISTAT, 1996a. 34 - A healthy start in life

Figure III.3: Voluntary abortions per 1 000 live births to mothers aged less than 20 years in selected EU countries – 1995. Countries

*1991 No. of abortions per 1 000 live births Source: WHO, 1999c.

Table III.5: Live births and abortions in mothers under 20 years of age in Italy, by region – 1995. ABORTIONS REGION NUMBER OF LIVE NUMBER OF PER 1 000 BIRTHS ABORTIONS LIVEBIRTHS (UNDER 20) MATERNAL AGE (YEARS) MATERNAL AGE (YEARS) <15 <20 <15 <20 Piemonte 437 23 1 054 2 411.9 Valle d’Aosta 12 0 23 1 916.7 Lombardia 797 26 1 591 1 996.2 Trentino Alto Adige 143 0 136 951.0 Veneto 1 444 5 505 1 137.4 Friuli Venezia Giulia 95 2 141 1 484.2 Liguria 99 5 310 3 131.3 Emilia Romagna 395 12 706 1 787.3 Toscana 339 14 681 2 008.8 Umbria 66 0 174 2 636.4 Marche 128 2 164 1 281.3 Lazio 538 16 1 121 2 083.6 Abruzzo 149 4 214 1 436.2 Molise 46 0 67 1 456.5 Campania 2 261 16 1 036 458.2 Puglia 1 708 18 1 412 826.7 Basilicata 102 2 147 1 441.2 Calabria 624 4 252 403.8 Sicilia 3 2 851 15 808 283.4 Sardegna 1 444 7 330 743.2 ITALY 5 11 678 171 10 872 931.0

Source: based on ISTAT 1997d. CHAPTER IV

NON-COMMUNICABLE DISEASES

CONTENTS

1. CARDIOVASCULAR DISEASES (CVDS)...... 36 1.1 Comparison of Italy with other countries...... 37 1.2 Comparison among different parts of Italy ...... 39 1.3 Incidence, prevalence and lethality ...... 39 2. CANCER ...... 40 2.1 Comparison of Italy with other countries...... 42 2.2 Comparison among different parts of Italy ...... 42 2.3 Selected cancer sites...... 46

3. DIABETES...... 54

4. CHRONIC RESPIRATORY DISEASES...... 55

5. MENTAL HEALTH DISORDERS...... 57 5.1 Prevalence ...... 57 5.2 Suicides...... 57 5.3 Care for mental health problems ...... 59 6. ALLERGIES AND INTOLERANCES...... 61 6.1 Asthma and allergic diseases ...... 61 6.2 Gluten-dependent entheropathy ...... 63

7. OTHER NON-COMMUNICABLE DISEASES ...... 64

8. ORAL HEALTH...... 64 36 - Non-communicable diseases

Non-communicable diseases, including cardio- lack of exercise and exposure to stress, remains vascular diseases, cancer, chronic obstructive essential in order to reduce the incidence and pulmonary diseases and mental disorders, rep- alter the course of non-communicable diseases. resent the greatest burden of mortality and On the other hand, several environmental and morbidity within the European Region as a occupational risk factors have been identified whole and in every Member State. and preventive policies can now be established. Factors of a different nature (e.g. genetic, bio- Screening and case-identification strategies logical, behavioural and environmental) deter- allow for early detection and diagnosis across mine individual risk to non-communicable dis- populations and within individuals. Treatment eases. has become increasingly effective for some con- At the individual level, the control of behaviour- ditions such as coronary heart diseases. Lastly, al and environmental risk factors, such as smok- rehabilitation remains an important component ing, alcohol abuse, obesity, excessive fat intake, of disease management for all conditions.

TARGET 8 – HEALTH21

By the year 2020, morbidity, disability and premature mortality due to major chronic diseases should be reduced to the lowest feasible levels throughout the Region

In particular: 8.1 mortality due to cardiovascular diseases in people under 65 years should be reduced on average by at least 40%, particularly in countries with currently high mortality; 8.2 mortality due to cancers of all sites in people under 65 should be reduced on average by at least 15%, with mortality due to lung cancer reduced by 25%; 8.3 the incidence of diabetes-related amputations, blindness, kidney failure, pregnancy complications and other serious health effects should be reduced by one third; 8.4 there should be a sustained and continuing reduction in morbidity, disability and mortality due to chronic respiratory diseases, musculoskeletal disorders and other prevalent chronic conditions; 8.5 at least 80% of children aged 6 years should be free of caries, and 12-year-old children should have on average no more than 1.5 decayed, missing or filled teeth

1. CARDIOVASCULAR DISEASES (CVDs) (ICD IX 410-414), 41 000 of which were among men. In the same year, a further 74 000 deaths Cardiovascular diseases are the main cause of were caused by cerebrovascular diseases (ICD IX death in Italy. In 1994, CVDs accounted for 430-438) (30 405 and 43 499 among males 242 621 deaths in Italy (43.6% of all deaths), and females, respectively) (ISTAT, 1997c). 111 039 of which were among males (38% of A more detailed analysis of Italian age-specific all deaths). The overall crude mortality rate was mortality patterns shows that cardiovascular 4.3 per 1 000 population. More than 74 000 diseases are the most frequent cause of death deaths were caused by ischaemic heart diseases among old people (39% and 53.9% of all Non-communicable diseases - 37

deaths in people aged 65-74 years or more and Europe (Figure IV.1); in Italy, this downward 75 years or more, respectively), whereas in the trend has been more pronounced, particularly age group 0-64 years CVDs, are the second in women, than the EU average (Figures IV.2a cause of death after cancer. and IV.2b). In 1993, Italy had one of the lowest EU rates for mortality from CVDs for both sexes 1.1 Comparison of Italy with other coun- aged 0-64 (approximately 48 per 100 000 in tries males and 26 per 100 000 in females). More specifically, deaths from ischaemic heart dis- The overall trend in age standardised death eases were substantially lower in Italy compared rates (SDRs)1 for CVDs (ICD IX: 390-459) in the to the rest of the EU, while mortality for cere- “relatively young” population, i.e. aged 0-64 brovascular diseases in Italy was close to the EU years, has been falling since 1970 in Western average.

Figure IV.1: Standardized death rate for circulatory system diseases* in subregional groups of countries in the WHO European Region. Age group 0-64.

Source: WHO, 1998b.

1 Standardised death rate: it represents what the crude death rate would have been in the study population if that population had the same distribution as a population taken as standard, with respect to the variable(s) for which the adjustment or standardization was carried out. This technique removes as far as possible the effects of differences in age or other confounding variables when comparing two or more populations (Last J., 1998). 38 - Non-communicable diseases

Figure IV.2a: Standardized death rate for circulatory system diseases* in EU countries in age group 0-64. Females. Time trend.

Source: WHO, 1999c.

Figure IV.2b: Standardized death rate for circulatory system diseases* in EU countries in age group 0-64. Males. Time trend.

Source: WHO, 1999c. Non-communicable diseases - 39

1.2 Comparison among different parts of For the age group 25-64 years, the attack-rates Italy for major coronary diseases estimated from the data of MONICA project are reported in Table Mortality rates for CVDs have been decreasing IV.1; attack rates are higher among men and in with time in all of the different parts of Italy, but the Northern areas. with specific sex and age patterns. A more marked decrease was observed among Figure IV.3a: Standardized death rate for cardiovascular diseases* by age males in Northern Italy, which at the end of the group in different areas of Italy. Males. Time trend. 1970s had the highest rates. In 1994, the rates observed in different parts of Italy are much closer. However, mortality rates for ischaemic heart diseases are still slightly higher in the North as compared to other parts of the country (1.2 and 1.1 per 1 000 for the North and the South respectively) (Figure IV.3a). Southern areas show the highest mortality rates for females, particularly among the elderly. More specifically, the greatest differences among Italian areas can be observed for cerebrovascular diseases, with high rates in the South (about 16 per 100 000 in Sicilia versus about 7 per 100 000 in Trento and Veneto). However, female mortality rates for ischaemic heart diseases are similar among the different areas (82.4, 81.4, and 88.1 per 100 000 in the North the South and in the Centre, respectively) (Figure IV.3b).

1.3 Incidence, prevalence and lethality

Incidence and prevalence of CVDs are not available from national surveys. However, some estimates have been calculated from mortality data by applying survival curves taken from the Ital- ian cardiovascular registers participating in the WHO MONICA project (Multinational MONItor- ing of trends and determinants of CArdiovascu- lar diseases). According to these estimates, at the beginning of the ‘90s there were 96 000 new ischaemic heart diseases per year in Italy, i.e. 61 000 men and 35 000 women. The estimated number of Italians currently affected by an ischaemic heart disease (ICD IX 410-414) is 489 000, of which 376 000 are men. Overall, 1% of the Italian population is estimated to have had an ischaemic heart disease (Ministry of Health of Italy, 1996). Source: data provided by ISS, 1999, unpublished. 40 - Non-communicable diseases

Figure IV.3b: Standardized death rate for cardiovascular diseases* by age 28 days of the attack. Furthermore, a large por- group in different areas of Italy. Females. Time trend. tion of subjects (45% men and 37% women) does not die in hospitals, particularly following secondary CV events. With respect to cerebrovascular pathologies, applying to the whole Italian population, the attack-rate observed in the age group 25-74 in the MONICA study, 38 100 estimated cerebrovascular events among men and 28 000 among women are expected to occur each year. Cumulative lethality, as reported in the Latina register, is as follows: 25.3% of men and 27.8% of women die within 24 hours; 35.9% of men and 42.8% of women die within 7 days; and 44.2% of men and 51% of women die within 28 days of the event. A relatively small proportion of people affected (19% and 23% for men and women, respectively) does not die in hospitals. In conclusion, a strong decrease in mortality for CVDs has been observed in Italy over the last few years. However, CVDs remain a major cause of mortality and morbidity in all areas of the country.

2. CANCER

Cancer is the second largest cause of mortality in the WHO European Region. In Italy, there are about 250 000 new cancer cases every year (135 000 among males and more than 115 000 among females). It has been estimated that 1 400 000 people in Italy had a cancer diagnosed in the last five years (Table IV.2), and that this number is increasing. Cancer represents the second cause of death among the Italian population, and is the first cause of death among people aged 0-64 years. More than 150 000 people (88 000 men and 62 000 women) died of cancer in 1994 (crude mortality rate 2.6 per 1 000). The most frequent cancer among men is lung Source: data provided by ISS, 1999, unpublished. cancer (29 000 new cases every year), which Cumulative lethality, as reported in the Latina caused about 26 000 deaths in 1994. The most register, is as follows: 8.3% of men and 8.6% frequent cancer among women is breast cancer of women die within one hour; 29.9% of men (more than 31 000 new cases every year), and 32.6% of women die within 24 hours, and which caused more than 11 000 deaths in 1994 56.5% of men and 73% of women die within (Table IV.2). Non-communicable diseases - 41

Table IV.1: Attack rate for coronary diseases among people aged 25-64 years in selected Italian areas.

MALES FEMALES Friuli Venezia Giulia Area (1984-1988) (Northern Italy) 35 8 Brianza Area (1985) (Northern Italy) 31 5 Latina Area (1983-1985) (Central Italy) 20 3

Source: Ministry of Health of Italy, 1996.

Table IV.2: Estimated number of yearly incident malignant neoplasms as well as number and percentage of all cancer deaths by site and sex in Italy - 1994.

NEW CASES DEATHS CANCER SITE MALES FEMALES MALES FEMALES NUMBER NUMBER NUMBER % OF ALL NUMBER % OF ALL CANCER CANCER Oral cavity 3 500 1 020 2 399 2 70 583 0.93 Oesophagus 1 830 520 1 801 2.03 496 0.79 Stomach 9 810 7 000 7 592 8.54 5 599 8.91 Colon-rectum 17 760 18 060 9 731 10.95 9 318 14.82 Pancreas 3 790 3 630 3 674 4.13 3 544 5.64 Larynx 4 800 290 2 060 2.32 152 0.24 Lung 28 880 5 760 25 933 29.17 4 952 7.88 Melanoma 1 083 1 950 698 0.79 567 0.90 Breast – 31 250 – – 11 343 18.04 Uterus, cervix – 3 550 – – 3 154 5.02 Uterus, corpus – 6 270 – – – – Ovary – 4 530 – – 2 885 4.59 Prostate 12 940 – 6 844 7.70 – – Bladder 14 640 3 200 4 530 5.10 1 078 1.71 Kidney 4 920 2 360 2 190 2.46 1 101 1.75 Non-Hodgkin Lymphomas 4 750 4 220 2 096 2.36 1 941 3.09 Hodgkin’s disease 780 750 254 0.29 251 0.40 Leukaemias 3 430 3 080 2 825 3.18 2 332 3.71 All malignant neoplasms 134 970 115 430 88 893 100 62 874 100

Source: Zanetti et al., 1998, modified. 42 - Non-communicable diseases

2.1 Comparison of Italy with other coun- the European Region; in Western European tries countries up to one in twelve women are affected, with incidence rates rising over time. Cancer mortality time trends for females and Age-specific mass-screening strategies using males in Italy reflect the EU trends (Figures IV.4a mammographies have been successfully intro- and IV.4b). In Western Europe, cancer mortality duced in some countries, with a reduction in standardized rates started declining in the observed mortality for breast cancer. Such 1980s and in 1997 were about 9% lower than strategies have also been introduced to detect in 1980 (when the age standardised cancer pre-invasive cervical cancers in many countries. mortality rate was around 92 per 100 000) In Italy, action in this field is mainly up to the (WHO, 1999b). However, most CCEE noted a individual Regions, Local Health Unit Agencies continuous increase in cancer mortality among and Hospital Agencies. people aged 0-64 years until 1990, with some Total cancer mortality has not fallen significant- levelling-off since then, which is mainly attrib- ly in the European Region, despite the consid- utable to the stabilisation or decline in lung erable resources devoted to detection, diagno- cancer mortality (WHO, 1997). sis and treatment. Inadequate management of In 1993, the Italian male death rate for all can- terminal cancer also remains a serious problem. cer types (aged 0-64 years) was the fifth high- For many people palliation remains poor, with est of the EU countries (106.6 per 100 000) and unnecessary suffering which reduces the quali- that for lung cancer was the fourth (35.1 per ty and dignity of the final stages of life. 100 000). However, Italy shows the highest decrease in male death rates for all cancers 2.2 Comparison among different parts of between 1983 and 1993 and the fourth high- Italy est decrease for male lung cancer. As was the case for males, Italy showed one of Total cancer mortality shows a marked North- the highest decreases in female death rates for South gradient. In 1994, the age standardized all cancers and one of the lowest increases in cancer death rates were, 3.04 per 1 000 for female lung cancer (Figures IV.5 and IV.6). In males in the North versus 2.34 per 1 000 in the 1993, female death rates (age 0-64) ranked South and for females 1.98 versus 1.62 per below the EU average, both for all cancers 1 000, respectively. However, the temporal (65.6 per 100 000) and for lung cancer (5.1 per trend in cancer mortality shows different pat- 100 000) (Figures IV.7a and IV.7b). terns according to age, sex and geographical The single most important risk factor for cancer areas (Figures IV.8a and IV.8b). is smoking, which is responsible for about one SDRs for overall cancer mortality among chil- third of all cancers in the European Region. For dren (aged 1-14 years) show a slow decrease instance, lung cancer mortality among women from 1970 on, particularly among females, in the Eastern part of the Region is lower than without any marked differences among areas. elsewhere, because of lower exposure to tobac- In the age group 15-44 years, a marked co smoking in the past. Diet, especially lack of decrease was observed during the same period fruit and vegetables coupled with a high satu- in cancer mortality for both sexes. This was rated fat intake, is an important risk factor for more pronounced in the Northern area which certain types of cancer. Other risk factors had the highest rates at the beginning of the include infectious agents (e.g. human papillo- 1970s; in 1994, the gap among areas almost mavirus for cervical cancer), hazardous industri- disappeared. al chemicals and occupational factors. In the age-group 45-64 years, a North-South In women, breast cancer remains the most gradient is still present in the most recent years. important cause of cancer mortality throughout A decrease in total cancer mortality rates in the Non-communicable diseases - 43

Figure IV.4a : Standardized death rate for malignant neoplasms in EU countries in the age group 0-64. Females. Time trend.

Source: WHO, 1999c.

Figure IV.4b: Standardized death rate for malignant neoplasms in EU countries in the age group 0-64. Males. Time trend.

Source: WHO, 1999c. 44 - Non-communicable diseases

Figure IV.5: Changes in standardized death rate for malignant neoplasms between 1983 and 1993 in age group 0-64 in EU countries.

Source: WHO, 1999c

Figure IV.6: Changes in standardized death rate for lung cancer between 1983 and 1993 in age group 0-64 in EU countries.

Source: WHO, 1999c Non-communicable diseases - 45

Figure IV.7a: Standardized death rate for lung cancer in EU countries in age group 0-64. Females. Time trend.

Source: WHO, 1999c.

Figure IV.7b: Standardized death rate for lung cancer in EU countries in age group 0-64. Males. Time trend.

Source: WHO, 1999c. 46 - Non-communicable diseases

Figure IV.8a: Standardized death rate for cancer in males (all sites) by age The same North-South gradient was group in different areas of Italy. Males. Time trend. observed for cancer incidence as recorded by the existing cancer registers (Figure IV.9). For both sexes, and for most of cancer sites, the risk of cancer in Trieste, Veneto or Varese (North of Italy) is higher than in Latina (Cen- tral Italy), and about twice as much that reported from Ragusa (South of Italy) (Zanet- ti et al., 1998).

2.3 Selected cancer sites

Trachea, bronchus and lung cancer A progressive increase in lung cancer mortality can be noted since 1970 for both sexes and throughout Italy. This trend can be attributed to the marked increase in the older age group (over 65 years) in both sexes and to a progressive increase among younger females. The North-South difference is considerable; for all age groups, the risk of dying from lung-cancer among males in the North is 30% higher than in the South. Trends in incidence rates are available from a few Italian registers. Among females, the incidence on the increase in all areas (Varese, Parma and Ragusa), irrespective of age. Among males, incidence rates are decreasing in Varese (North), particularly among the younger age group, while in Parma and Ragusa they are still increasing, although more slowly than in previous years (Zanetti et al., 1998). Overall lung cancer survival at five years is poor, although some important differences exist, both among European countries and among Italian areas (Zanetti et al., Berrino et al., 1998) (Figures IV.10 and IV.11).

Source: data provided by ISS, 1999, unpublished. Breast Cancer in females A marked North-South difference exists in both last years can be observed in Northern and mortality and incidence associated with breast Central Italy, while there was a small increase cancer (Figures IV.12 and IV.13). over the same period in the South for males. The mortality trend is on the increase, with The largest change over time since 1970 was higher rates in Northern Regions. For all ages, observed among those aged 65 years and incidence is increasing in the Varese and Parma above: for both sexes and all areas, the cancer Registers (Northern Italy), while it is stable in mortality rates were on the increase. the Ragusa register (Southern Italy). Non-communicable diseases - 47

Breast cancer survival at five years shows Figure IV.8b: Standardized death rate for cancer in females (all sites) by marked differences among the European Coun- age group in different areas of Italy. Females. Time trend. tries; the best results are observed in Switzer- land (76%) while the worse are in the UK (63%). Survival in Italy, reported as an average of existing registers, is 72%; this value reflects a marked heterogeneity with values ranging from 65% in Ragusa to an excellent 86% in Ferrara.

Stomach cancer Mortality rates for stomach cancer have progressively declined over the last few decades, for both sexes (Figures IV.14a and IV.14b). The same trend was observed for incidence. The highest mortality and incidence rates are observed in the Central and Northern areas. Incidence rates observed in the Romagna, Firenze and Parma Registers (44.6; 31.8 and 29.0 per 100 000, respectively) are among the highest in Europe (Zanetti et al., 1998). Average stomach cancer survival at five years in Italy is 19% (values ranging from 14% in Ragusa to 26% in Ferrara) compared to a range which goes from 9% in the UK to 26% in Switzerland (Figure IV.15).

Colo-rectal cancer Colo-rectal cancers are the second most frequent neoplasm for both sexes. Overall mortality rates are increasing in all the areas (Fig- ures IV.16a and IV.16b). Again, a marked North-South gradient is present, both for mortality and for incidence. Colon cancer incidence rates observed in the Ragusa register (South) for males are about one third of those observed in the Trieste register (North- East) (Figure IV.17). Incidence rates are increasing for both sexes in Parma and Varese Source: data provided by ISS, 1999, unpublished. areas (North), while they are stable in Ragusa (South). The same is also observed for rectum cancer. Cancer in children As regards colon cancer, the survival percentage Detailed data for cancer in children are avail- at five years for men in Europe ranges from able from the Infant Cancer Register of 35% in the UK to 51% in Switzerland (Figure Piemonte (Northern Italy) (Table IV.3). The most IV.18), while in Italy it ranges from 34% in frequent cancer types are leukaemias, lym- Ragusa to 57% in Ferrara. phomas and cancer of the central nervous sys- 48 - Non-communicable diseases

Figure IV.9: Cancer incidence (all sites) according to Italian cancer registers. Average yearly rates (period 1988-1992).

Source: Zanetti et al., 1998.

Figure IV.10: Lung cancer: overall survival rate at five years of cases diagnosed in the first half of 1980s in selected EU countries.

Source: Berrino et al., 1995; Verdecchia et al., 1997. Non-communicable diseases - 49

Figure IV.11: Lung cancer: overall survival rate at five years of cases diagnosed between 1988-1992 according to Italian cancer registers.

Source: Verdecchia et al., 1997.

Figure IV.12: Standardized deaths rate for breast cancer in different areas of Italy. Females. Time trend.

Source: data provided by ISS, 1999, unpublished. 50 - Non-communicable diseases

Figure IV.13: Breast cancer incidence according to Italian cancer registers. Average yearly rates (period 1988-1992).

Source: Zanetti et al., 1998.

Figure IV.14a: Standardized death rate for malignant stomach neoplasms in different areas of Italy. Females. Time trend.

Source: data provided by ISS, 1999, unpublished Non-communicable diseases - 51

Figure IV.14b: Standardized death rate for stomach malignant neoplasms in different areas of Italy. Males. Time trend.

Source: data provided by ISS, 1999, unpublished.

Figure IV.15: Stomach cancer: overall survival rate at five years of cases diagnosed in the first half of 1980s in selected EU countries.

Source: Berrino et al., 1995; Verdecchia et al., 1997. 52 - Non-communicable diseases

Figure IV.16a: Standardized deaths rate for intestine, colon and rectum malignant neoplasms in different areas of Italy. Females. Time trend.

Source: data provided by ISS, 1999, unpublished.

Figure IV.16b: Standardized deaths rate for intestine, colon and rectum malignant neoplasms in different areas of Italy. Males. Time trend.

Source:data provided by ISS, 1999, unpublished. Non-communicable diseases - 53

Figure IV.17: Colon cancer incidence according to Italian cancer registers. Average yearly rates (period 1988-1992).

Source: Zanetti et al., 1998.

Figure IV.18: Colon cancer: overall survival rate at five years of cases diagnosed in the first half of 1980s in selected EU countries.

Source: Berrino et al., 1995; Verdecchia et al., 1997. 54 - Non-communicable diseases

Table IV.3: Infant cancer registry of Piemonte. Annual incidence observed in the period 1990-1994.

AGE STANDARDIZED RATES TYPE OF CANCER PER MILLION CHILDREN (STANDARD ITALY 1981)

MALES FEMALES Leukaemias 60.8 51.8 Lymphomas 30.0 10.7 Central nervous system 39.6 32.4 Neuroblastomas 12.9 8.6 Retinoblastomas 4.6 5.8 Kidney 5.0 8.4 Bone 7.4 10.9 Sarcomas 10.0 9.5 Gonadi 1.3 2.9 Others 5.7 10.6

ALL TYPES 177.3 151.6

Source: Zanetti et al., 1998, modified

tem. In Italy both incidence and mortality rates tality rates among females in 1993 were 20.5 are comparable to those observed in other versus 14.3 per 100 000 in EU countries (range western countries (Zanetti et al., 1998). 6.7-26.8) and, among males, 19.1 versus 14.9 per 100 000 (range 6.6-26.9). The estimated incidence of insulin-dependent 3. DIABETES diabetes mellitus (IDDM) among Italian children 0-14 years of age ranges from 8 to 12 per Diabetes is estimated to affect between 25 and 100000. However, incidence rates in the Sardeg- 40 million people in the European Region. When na Region are much higher (34.4 per 100 000) not properly treated, it may shorten the lifespan and are close to the highest in Europe, which and have many seriously adverse effects on were reported in Finland (36.4 per 100 000) health (such as blindness, kidney failure, amputa- (Karvonen et al., 1998; Songini, 1998). tion and acute blood sugar crises). Diabetes is The estimated prevalence rate of IDDM also one of the major risk factors for cardiovas- observed in the population 65-84 years old cular diseases and, if it occurs during pregnancy, (ILSA study - Italian Longitudinal Study on Age- it poses a major risk to both mother and child. ing) is 13.4% among men and 12.9% among Although mortality from diabetes shows stable women (ILSP, 1997). Data on incidence and or decreasing trends in Central and Eastern prevalence of diabetes complications are scarce Europe as well as in Western Europe, there are and comprehensive programmes for the detec- rising trends after an initially lower rate in the tion and control of diabetes and its complica- NIS, possibly due to the high prevalence of obe- tions are necessary in order to monitor the sity (Figure IV.19). effectiveness of control policies. According to mortality data, Italy ranks second In Western Germany, the annual incidence rates highest among the EU countries. In Italy, mor- for blindness were found to be 60.6 per Non-communicable diseases - 55

Figure IV.19: Standardized death rate for diabetes in subregional groups of countries in the WHO European Region. Time trend.

Source: WHO, 1999c.

100 000 among the diabetic population 4. CHRONIC RESPIRATORY DISEASES (against 11.6 in the non-diabetic population) (Trautner et al., 1997). According to EURODIAB The prevalence of chronic obstructive pul- IDDM Complications Study, the frequency of monary diseases in some European countries is mild non-proliferative retinopathy was found to reported to be in the range 2-7%, with a major be 25.8% of the 3 250 insulin-dependent impact on the quality of life, disability, health patients studied; moderate-severe non-prolifer- care costs and work absenteeism. ative retinopathy was found in 9.8% of the Mortality for diseases of the respiratory system patients and proliferative retinopathy in 10.6% (ICD IX 460-519) has been decreasing over the of the patients (Sjolie et al., 1997). Among the last 20 years in EU countries. Compared to 4 549 cases of certified blindness cases other countries, Italy shows mortality rates between 1967 and 1991 in the Province of (about 6% of total mortality) which are below Turin, diabetic retinopathy was found to be the the EU average. In 1993, the mortality rates second commonest cause of bilateral blindness among females were 22.7 in Italy versus 41.8 (13.1% of all cases) after cataract (26.7%) per 100 000 as an EU average (range 22.7- (Porta et al., 1995). Neuropathy affected 95.3). Among men, the rates were 61.6 in Italy 32.3% of 8 757 Italian diabetic patients (mean versus 88.7 per 100 000 as an EU average (HFA age 56 years) (Fedele, 1997). database, 1999). 56 - Non-communicable diseases

Figure IV.20a: Standardized death rate for chronic respiratory diseases* in different areas of Italy. Males. Time trend.

Source: data provided by ISS, 1999, unpublished.

Figure IV.20b: Standardized death rate for chronic respiratory diseases* in different areas of Italy. Females. Time trend.

Source: data provided by ISS, 1999, unpublished. Non-communicable diseases - 57

Mortality rates are seen to decrease throughout population suffering from severe problems (as in Italy. Rates are higher in the South than in the registered and reported by countries) varies North and in males as compared to females from under 1% to as much as 6%, with most (Figures IV.20a and IV.20b). countries in the range of 1-3%. According to Mortality in this group is almost completely the World Bank and WHO, calculations based attributable to chronic bronchitis and emphyse- on DALYs, the three major psychiatric disorders ma. Among chronic respiratory diseases, asth- – depression, bipolar disorder and schizophre- ma also deserves particular attention (see also nia – constituted 9.5% of the total burden of section 6.1). disease and disability in Europe in 1990. Other problems with significant psycho-social manifestations include: Alzheimer’s disease; 5. MENTAL HEALTH DISORDERS other dementias and degenerative central nervous system disorders, alcohol and drug use Risk factors for mental health problems are and dependence; anxiety and sleep disorders. increasing. These include unemployment and A national health survey carried out in Italy poverty, migration, political upheaval, growing between 1987 and 1991 showed a 2.8% tensions between ethnic and other groups prevalence of mental health problems in the (especially in major cities), increasing homeless- population aged 6 years and over (ISTAT, 1995). ness, greater substance abuse, loneliness and breakdown of social networks and socio-eco- 5.2 Suicides nomic upheaval and deprivation. Suicide is a common cause of death in adoles- 5.1 Prevalence cents and younger adults (responsible for as much as 15% of deaths in 15-24 year olds), It is difficult to assess and compare the preva- where it is often related to alcohol and drug lence of mental health problems in different use. Among people less than 20 years of age, countries, especially because there are inherent suicide rates are higher in males than in females culture-related differences in the definition of in the EU countries, ranging from 3.5 per mental health. 1 000 000 in Portugal to 43.0 in Finland for In any case, data from the European Region as males, and from 1.5 in Austria to 8.3 in Norway a whole indicate that the proportion of the for females. In general, Italy has age specific

TARGET 6 - HEALTH21

By the year 2020, people’s psychosocial wellbeing should be improved and better comprehensive services should be available to and accessible by people with mental health problems.

In particular: 6.1 the prevalence and adverse health impact of mental health problems should be substantially reduced and people should have an increased ability to cope with stressful life events; 6.2 suicide rates should be reduced by at least one third, with the most significant reductions achieved in countries and population groups with currently high rates. 58 - Non-communicable diseases

death rates for suicide among young people The average rate for the EU started declining below the median value in the EU. Rates are slowly in the mid-1980s (Figure IV.22). Com- particularly low for females (4.5 per 1 000 000) pared to other Western European countries, (Figures IV. 21a and IV. 21b). Italy shows one of the lowest suicide rates after Suicide is increasing among older people, espe- Greece: in 1993, the overall rate (7.22 per cially in the NIS, and among men aged 85 and 100 000 population) was about one fourth of older. The average suicide rates in the NIS shows that observed in Finland, the EU country with a typical U-shaped trend from 1980s to the mid- the highest rate (Figure IV.23). 1990s, caused by the temporary improvement The average male suicide rate in Italy was 11.65 resulting from the anti-alcohol campaign in per 100 000 population, compared with 3.41 1985, the subsequent end of the campaign and per 100 000 population among females, i.e. the influence of the socio-economic transition. about three times lower than that observed in Since the end of the 1980s, trends in the suicide men. However, patterns were markedly different rate have been declining in 26 countries (45.7% in different Italian Regions (Table IV.4): suicide of the population), including 9 countries where rates are higher in the North than in the Centre increasing trends had been reversed since 1980; and South, although the size of the difference in 17 countries (44.8% of the population), sui- tended to decrease over the last years recorded. cide rates are increasing. No data are available As for age specific rates, the highest Italian val- for 8 countries. ues can be observed among people aged 70

Figure IV.21a: Age specific death rates from suicides in age group 0-19 in EU countries. Males. Last available year.

Source: ISTAT, 1998a. Non-communicable diseases - 59

Figure IV.21b: Age specific death rates from suicides in age group 0-19 in EU countries. Females. Last available year.

Source: ISTAT, 1998a.

years and over (18.5 suicide per 100 000 pop- within local communities close to where patients ulation in 1992), particularly among males live and possibly work, although for various man- (34.3 deaths per 100 000 population). In the agerial and financial reasons this has been difficult latter age group, a decrease in suicide rates was to fully achieve. Ideally, such local care systems observed over the last years (from 41.7 per should offer mental health promotion and disease 100 000 in 1988 to 34.3 per 100 000 in 1992). prevention services to local communities, as well However, among young adults (15-29 years), a as treatment close to the patient’s home in close small increase was detected (from 6.4 in 1988 collaboration with local primary care services. to 7.8 per 100 000 population in 1992) (Min- However, the WHO European Region still has over istry of Health of Italy, 1996). 100 very large psychiatric hospitals, or “asylums”, almost all of which are in the Eastern part. Many 5.3 Care for mental health problems of these are in poor conditions and often provide outmoded care facilities. There appear to be marked differences in the pre- In 1978, the Italian psychiatric reform (Law no. vailing doctrines of psychiatric care between 180) established the statutory prohibition of countries in Western and Eastern Europe. Many admitting patients to psychiatric hospitals and countries in Western Europe have attempted to the implementation of a community care reduce the number of inpatient beds and to approach. Inpatients have been progressively adopt an approach based on the provision of care discharged from psychiatric hospitals (from 60 - Non-communicable diseases

Figure IV.22: Standardized death rate for suicides in subregional groups of countries in the WHO European Region. Time trend.

Source: WHO, 1998c.

Figure IV.23: Standardized death rate for suicides in EU countries. All ages – 1995.

Source: WHO, 1999c. Non-communicable diseases - 61

74 000 inpatients in 1978 to about 6 600 in 6. ALLERGIES AND INTOLERANCES September 1997) (ISTAT, 1998a). However, the number of inpatient admissions of acute cases 6.1 Asthma and allergic diseases into the psychiatric services of general hospitals is on the increase: there were 130 000 admis- The frequency of atopic diseases has increased sions in 1995 (about 23 per 100 000 popula- world-wide over the last few decades. It has tion), 115 000 admissions in 1993 and 103 000 been estimated that allergic diseases affect as in 1990. Since only a quarter of these hospital much as 35% of the general population. Prin- admissions are first admissions, most of the cipal factors responsible for the increasing patients are likely to be chronically ill, possibly prevalence of allergic diseases include: indoor looking for care in hospitals given the lack of pollution caused by house-dust mites, cock- provision for proper outpatient services and roaches, pets (especially cats), and tobacco assistance (ISTAT, 1996a). smoke; outdoor pollution caused by ozone,

Table IV.4: Suicide rates in Italy by Region

REGION RATE PER 100 000 1988 1992 DIFF.% Piemonte 11.39 11.39 0.00 Valle d'Aosta 16.74 12.87 –23.12 Liguria 9.63 10.11 4.98 Lombardia 7.46 7.96 6.70 Trentino 10.01 10.85 8.39 Veneto 8.45 7.68 –9.11 Friuli Venezia Giulia 12.29 11.46 –6.75 Emilia Romagna 12.86 12.90 0.31 Marche 8.24 8.17 –0.85 Toscana 8.65 10.00 15.61 Umbria 10.14 9.10 –10.26 Lazio 5.97 5.65 –5.36 Campania 3.76 4.73 25.80 Abruzzo 6.06 6.39 5.45 Molise 5.76 5.44 –5.56 Puglia 4.78 5.25 9.83 Basilicata 6.71 5.73 –14.61 Calabria 4.56 5.31 16.45 Sicilia 6.71 6.48 –3.43 Sardegna 8.64 9.27 7.29

NORTH 9.64 9.69 0.52 CENTRE 7.45 7.64 2.55 SOUTH 5.41 5.82 7.58

ITALY 7.69 7.89 2.60

Source: Ministry of Health of Italy, 1996. 62 - Non-communicable diseases

particulate matter (diesel), NO2 and SO2, which stimuli at a level which does not induce such can precipitate symptoms in asthmatic narrowing in most individuals”. Prevalence of patients, or may favour IgE sensitisation and allergic asthma increased approximately the ensuing development of allergic diseases; twofold during 1980. Table IV.6 shows esti- changed lifestyles, new dietary habits and mates of the prevalence rates of asthma in hygienic conditions. adults aged more than 15 years. The data available for some of the major allergic diseases are mainly based on local questionnaire surveys and health data. Estimates of the Table IV.6: Asthma prevalence rate (per prevalence of allergic diseases are highly depen- 100) in adults in selected Euro- dent on the adopted definition of the diseases. pean countries. Comparison among several countries as well as changes in prevalence over time may, therefore, >15 YEARS prove difficult; the results of the study reported Finland 1.8-2.5 below should be regarded as indicative rather France 3.7-7.4 than definitive (AAVV, 1995). Denmark 6.0 The occurrence of hay fever has increased since Germany 1.8 the early twentieth century; in Europe, preva- Italy 5.0 lence rates for hay fever are between 10 and Sweden 2.8 20%. The present prevalence of seasonal aller- UK 3.8-4.3 gic rhinitis in various European countries is Source: AAVV, 1997. shown in Table IV.5.

Table IV.5: Hay fever prevalence rates (per A world-wide study of asthma in children was 100) in children and adults in recently carried out using a standardized protocol selected European countries. and questionnaire (ISAAC: International Study of Asthma and Allergies in Childhood) (ISAAC, <15 YEARS ≥15 YEARS 1998). Ireland and UK show the highest estimat- Finland 6.0 14.0 ed prevalence of current wheezing and asthma France 3.0 5.9-18.5 among 6-7 years-old children (Table IV.7). The Denmark 3.2 prevalence of both current wheezing and asthma Germany 7.2-18.5 9.5-19.6 in the European countries ranges from 3.7 % in Italy 13.1 Greece to about 30 % in Ireland and UK in chil- Norway 10.0 dren aged 13-14 years (Table IV.8). Spain 4.9 Asthma prevalence in children has recently Sweden 10.8 8.5 been evaluated through an Italian multicentre Switzerland 6.1-16.8 study (SIDRIA - Studi Italiani sui disturbi respira- UK 11.9-14.9 10.9-16.5 tori nell’Infanzia), and is an extension of the ISAAC study (SIDRIA, 1995). The overall esti- Source: AAVV, 1997. mated prevalence of asthma in Italy is 9.0% among children aged 6-7 years and 9.9% Allergic asthma has been defined by the World among those aged 13-14 years, without any Health Organisation as “a chronic condition major differences among the Italian areas. characterised by recurrent bronchospasms, Prevalence of self-reported current asthma- resulting from a tendency to develop reversible symptoms in adolescents is equal to 10.3%. narrowing of the airways in response to various This is one of the lowest rates among the coun- Non-communicable diseases - 63

tries participating in the ISAAC study (SIDRIA, It is important to stress that in Europe, the mor- 1997; ISAAC, 1998). tality rate for asthma has remained low compared to other parts of the world. Other allergic diseases, such as allergic atopic Table IV.7: Prevalence rates (per 100) of dermatitis, have been extensively studied; in current asthmatic symptoms particular, Shultz et al analysed data from 1991 and of life-time asthma in 6-7 to 1992 (Shultz et al., 1993). Results from this years old children in the West- study show that the cumulative incidence of ern Europe centres collaborat- atopic dermatitis before the age of seven has ing with the ISAAC study. dramatically increased. The prevalence of this disease is 10-12 % and is slightly higher in CENTRE CURRENT EVER HAD females than in males. Moreover, it has been WHEEZING ASTHMA observed that 10-20 % of children with atopic Austria 8.9 3.9 dermatitis will develop asthma later in life. Belgium (Antwerp) 7.3 4.2 These findings strongly suggest that atopic der- Germany 8.5 3.6 matitis has become a major problem in Europe. Greece (Athens) 7.6 5.4 Data on the prevalence of allergic contact der- Italy 7.3 8.6 matitis are incomplete; in the general popula- Portugal 13.2 11.0 tion, it is estimated to be around 1%. Several Spain 6.2 6.2 studies attribute this to an increasing sensitivity UK (Sunderland) 18.4 22.9 towards nickel, which is considered the major cause as it is contact sensitiser. Some 10-25% Source: ISAAC, 1998. of the female population studied seems to be affected by it.

Table IV.8: Prevalence rates (per 100) of 6.2 Gluten-dependent entheropathy current asthmatic symptoms and of life-time asthma in 13-14 It is well know that in Europe, 1 out of 1 000 years old children in the West- people and in some European countries possi- ern Europe centres collaborat- bly even more, have no tolerance to the alco- ing with the ISAAC study. hol-soluble protein fraction present in bread CENTRE CURRENT EVER HAD wheat and wheat products as well as in some WHEEZING ASTHMA other cereals (e.g. barley and rye), showing sooner or later small-bowel atrophy with fre- Austria 11.6 6.0 quent associated malabsorption and several Belgium 12.0 8.1 other very serious symptoms (Greco et al., Finland 16.0 6.6 1992; Mäki and Collin, 1997; Silano and De France 13.5 12.6 Vincenzi, 1999). Germany 13.8 5.7 Gluten-dependent entheropathy is referred to Greece 3.7 4.5 as coeliac disease in children or nontropical Italy 8.9 9.9 sprue in adults. Diagnosis has greatly improved Portugal 9.5 12.1 in recent years following the widespread use of Ireland 29.1 15.2 sensitive blood tests. Spain 10.3 10.5 Recent screening studies have found a prevalence Sweden 12.9 10.4 of 1 in 300 (Grodzinsky et al., 1992; Catassi et al., UK 32.2 20.7 1994) and it has been suggested that the preva- Source: ISAAC, 1998. lence might be as high as 1 in 100 individuals (Mc 64 - Non-communicable diseases

Millan et al., 1996); however, this finding is on the of people affected by rare diseases from paying basis of the occurrence of endomysial antibodies for the necessary medical care. only. Nevertheless, it is clear that diagnosing symptomatic coeliac disease only represents the Data on prevalence of a few diseases, relatively tip of the iceberg. In contrast to other countries, frequent in the Italian population are reported the incidence of coeliac disease in children in Swe- below (Tamburlini G., personal communication, den has increased during the past 15 years to 1999). more than 1 in 300: this is probably due to a larger amount of gluten in the diet of young infants. Cystic fibrosis is a disorder occurring in infancy Recent investigations report a prevalence rate in and childhood which affects many organs and Italy of 1 case in 184 people (Greco L., personal is transmitted as an autosomal recessive trait. In communication, 1999). Italy, estimates indicate a frequency of 1 case per 4 800 population.

7. OTHER NON-COMMUNICABLE DISEASES Thalassemia major is a congenital disorder in which there is a defect in the synthesis of one Rare diseases, in most cases genetic in origin, or more of the haemoglobin subunits. As a have been identified as a priority for European result of the decreased haemoglobin produc- Community action within the framework of tion, the red blood cells are hypochromic and public health. The “Action Programme 1999- mycrocit. Thalassemia is found primarily in peo- 2003” gives information regarding the defini- ple from the Mediterranean basin, due to the tion of rare diseases, indicating them as dis- decreased production of beta chains of haemo- eases affecting less than 5 per 10 000 popula- globin. In Italy, there are certain areas (Sardeg- tion. Over 5 000 rare diseases are currently na Region, Ferrara province) where the disease identified and, despite their very low preva- is or was once more common; the frequency lence, affect a significant percentage of the within the Italian population is estimated at 1 overall population. per 5 000-8 000 population. Rare diseases are life-threatening or chronically debilitating diseases with such a low prevalence Another genetic disorder encountered within that a special combined effort is needed to the category of rare diseases is phenylke- address them. In addition, rare diseases are an tonuria, a metabolic disorder secondary to an important social problem as well as a challenge inherited deficiency of phenylalanine hydroxy- for medical science. Most rare diseases are, in lase. The accumulation of phenylalanine and fact, chronic and extremely weakening. Ensur- some of its metabolites results in a complex ill- ing highly effective health care for individuals ness with a mental disorder syndrome; in Italy with rare diseases requires a considerable approximately 1 case out of 12 000 population amount of knowledge to be made available to is reported. patients, health care professionals and The above mentioned European Action Pro- researchers. In order to obtain a precise picture gramme 1999-2003 has identified a number of of the prevalence of rare diseases within the community activities to help control these dis- country, the Italian Ministry of Health has estab- eases. lished a National Registry in collaboration with the National Institute of Health. Within the framework of the new definition of cost shar- 8. ORAL HEALTH ing and payment exemptions (under legislative Decree 24 April 1998, no. 124), a national Good oral health contributes not only to the scheme has been approved for the exemption quality of life but also to preventing diseases of Non-communicable diseases - 65

the digestive system, including cancer. Major although there has been a deterioration in the efforts in preventing and treating oral diseases eastern part of the Region (Table IV.9). People over the last decade have improved the oral keeping their teeth for life have increasingly health status in most European countries, become the norm in the Western Europe.

Table IV.9: Average number of decayed, missing and filled permanent teeth among 12- years-old children and average number of missing teeth per person among people 35-44 years old in selected areas of Western European countries.

DECAYED, MISSING AND FILLED MISSING TEETH COUNTRY PERMANENT TEETH – 12 YEARS OLD 34-35 YEARS OLD

1985 1989 LAST AVAILABLE 1989 LAST AVAILABLE YEAR YEAR Austria 4.0 4.2 4.2 7.4 7.4 Belgium 3.1 3.9 2.7 n.a. n.a. Denmark 3.4 1.6 1.3 4.5 4.5 Finland 3.0 2.0 1.2 13.5 13.0 France 3.4 4.2 2.6 n.a. n.a. Germany 6.2 4.1 2.6 n.a. n.a. Greece 4.7 4.3 4.4 5.6 5.6 Iceland 7.7 5.0 2.3 n.a. 3.7 Ireland 2.7 n.a. 1.6 10.6 12.6 Italy 4.0 3.0 2.6 n.a. 5.4 Luxembourg n.a. 3.0 2.3 n.a. n.a. Netherlands 2.4 1.7 0.9 4.6 4.6 Norway 4.4 2.7 2.1 3.0 3.0 Portugal 3.8 3.2 3.2 6.7 6.7 Spain 4.2 n.a. 2.3 5.6 4.7 Sweden 3.4 2.2 1.5 5.0 n.a. Switzerland 3.0 2.3 2.3 6.2 6.2 United Kingdom 3.0 3.1 1.4 9.2 6.9

Source: WHO,1998b,modified. CHAPTER V

COMMUNICABLE DISEASES

CONTENTS

1. INCIDENCE OF COMMUNICABLE DISEASES IN ITALY ...... 68

2. COMMUNICABLE DISEASES TARGETED FOR ERADICATION ...... 69 2.1 Poliomyelitis ...... 69 2.2 Tetanus ...... 70 2.3 Measles ...... 71

3. COMMUNICABLE DISEASES TARGETED FOR BETTER CONTROL . . . 75 3.1 Diphtheria ...... 75 3.2 Congenital rubella ...... 75 3.3 Mumps ...... 75 3.4 Pertussis ...... 75 3.5 Haemophilus influenzae type B disease ...... 75 3.6 Hepatitis ...... 77 3.7 Acquired Immunodeficiency Syndrome (AIDS) ...... 78 3.8 Sexually transmitted diseases (STDs) ...... 79 3.9 Tuberculosis ...... 83 3.10 Malaria ...... 83 3.11 Influenza ...... 85 3.12 Foodborne infections ...... 85

4. ANTIBIOTIC RESISTANCE ...... 85 68 - Communicable diseases

1. INCIDENCE OF COMMUNICABLE DIS- because of under-reporting. Even for an impor- EASES IN ITALY tant infectious disease like tuberculosis, a study conducted in the Florence area in 1995 showed More than 296 461 cases of infectious disease, 50% under-reporting (Buiatti et al., 1998). Sim- for which notification is mandatory, were ilarly, conspicuous under-reporting has been recorded in Italy in 1996 (Table V.1). However, it suggested for tetanus infections for some should be stressed that, although notification is Regions of Southern Italy, as indicated by the mandatory, incidence of many widespread ratio between the number of deaths and the communicable diseases in Italy, as well as in number of cases reported (greater or equal to many other countries, is often under-estimated 1) (Table V.2).

Table V.1: Cases and rates (per 100 000 population) of selected infectious diseases recorded in Italy, by geographical areas – 1996. NORTH CENTRE SOUTH ITALY NUMBER RATES NUMBER RATES NUMBER RATES NUMBER RATES Blenorrhea 252 0.99 102 0.93 11 0.05 365 0.64 Botulism 12 0.05 5 0.05 41 0.20 58 0.10 Brucellosis 186 0.73 69 0.63 1 641 7.86 1 896 3.31 Infectious diarrhea 1 106 4.35 377 3.43 583 2.79 2 066 3.60 Hepatitis A 1 232 4.84 529 4.81 6 890 32.99 8 651 15.09 Hepatitis B 1 145 4.50 420 3.82 683 3.27 2 248 3.92 Hepatitis nA nB 428 1.68 172 1.56 549 2.63 1 149 2.00 Hepatitis not specified 138 0.54 23 0.21 233 1.12 394 0.69 Typhoid fever 64 0.25 145 1.32 883 4.23 1 092 1.90 Legionellosi 108 0.42 18 0.16 2 0.01 128 0.22 Leishmaniasis (cutaneous) 3 0.01 2 0.02 28 0.13 33 0.06 Leishmaniasis (visceral) 21 0.08 21 0.19 103 0.49 145 0.25 Leptospirosis 60 0.24 7 0.06 7 0.03 74 0.13 Listeriosis 18 0.07 6 0.05 16 0.08 40 0.07 Malaria ------760 1.33 Meningococcal meningitis 105 0.41 66 0.60 83 0.40 254 0.44 Meningoencephalitis 268 1.05 236 2.15 403 1.93 907 1.58 Mycobacterial disease 308 1.21 37 0.34 5 0.02 350 0.61 Measles 7 243 28.46 6 202 56.41 19 151 91.68 32 596 56.85 Mumps 37 266 146.43 15 735 143.12 11 700 56.01 64 701 112.85 Pertussis 1 747 6.86 1 052 9.57 1 096 5.25 3 895 6.79 Rickettsiosis 99 0.39 212 1.93 1 038 4.97 1 349 2.35 Rubella 12 343 48.50 6 032 54.86 3 503 16.77 21 878 38.16 Salmonella infections 9 303 36.55 3 076 27.98 3 181 15.23 15 560 27.14 Scarlattiniform eruption 19 796 77.78 4 305 39.16 1 491 7.14 25 592 44.64 Syphilis 284 1.12 112 1.02 41 0.20 437 0.76 Tetanus 53 0.21 30 0.27 22 0.11 105 0.18 Tuberculosis (not lung) 1 040 4.09 233 2.12 217 1.04 1 490 2.60 Tuberculosis (lung) 2 229 8.76 849 7.72 944 4.52 4 022 7.02 Tularaemia 4 0.02 5 0.05 1 0.00 10 0.02 Chickenpox 67 122 263.73 21 671 197.11 15 423 73.84 104 216 181.77 TOTAL 163 983 644.32 61 749 561.64 69 969 334.97 296 461 517.09 Sour ce: Ministr y of Health of Italy , 1999a. Communicable diseases - 69

Table V.2: Case fatality ratio for tetanus in Italy - 1991-1993.

REGION NUMBER OF NUMBER OF CASE - FATALITY REPORTED DEATHSb RATIOc CASESa Piemonte 35 19 0.54 Valle d’Aosta 1 0 – Lombardia 38 10 0.26 Trentino Alto Adige 2 0 0.00 Veneto 16 8 0.50 Friuli Venezia Giulia 5 2 0.40 Liguria 10 7 0.70 Emilia Romagna 40 11 0.28 Toscana 37 16 0.43 Umbria 14 5 0.36 Marche 19 2 0.11 Lazio 9 8 0.89 Abruzzo 7 3 0.43 Molise 1 0 – Campania 22 18 0.82 Puglia 3 7 2.30 Basilicata 1 1 1.00 Calabria 5 6 1.20 Sicilia 2 9 4.50 Sardegna 2 2 1.00 ITALY 269 134 0.50 a Source: National epidemiological bulletin, Rome, Ministry of Health. b Source: ISTAT, 1997c. c Case-fatality ratio= (No. deaths)/(No. reported cases). Source: Prospero et al., 1998.

Comparison among areas as well as time trends The WHO campaign to eradicate poliomyelitis should therefore be interpreted with caution, has been successfully implemented in the since they could mainly reflect different attitudes European and Eastern Mediterranean Regions towards notification, rather than real attitudes. through “Operation MECACAR”. From 1995 to 1997, the overall immunisation coverage was close to 95%. Nevertheless, the recent 2. COMMUNICABLE DISEASES TARGETED severe outbreak of poliomyelitis in Albania FOR ERADICATION (139 cases in 1996 with an incidence rate of 4.22 per 100 000), which also affected areas 2.1 Poliomyelitis in neighbouring countries, has demonstrated the fragility of the achievements toward elim- No autochthonous cases of poliomyelitis by inating the disease in some parts of the wild poliovirus have been recorded in Italy since Region. 1983; the very last case of wild poliovirus Polio immunisation has been mandatory in poliomyelitis in Italy was an imported case Italy since 1966; previously, polio immunisa- which occurred in 1988. tion was performed on a voluntary basis in 70 - Communicable diseases

TARGET 7 - HEALTH21

By the year 2020, the adverse health effects of communicable diseases should be substantially diminished through systematically applied programmes to eradicate, eliminate or control infectious diseases of public health importance.

In particular:

Elimination of disease

7.1 by 2000 or earlier, poliomyelitis transmission in the Region should stop, and by 2003 or earlier this should be certified in every country;

7.2 by 2005 or earlier, neonatal tetanus should be eliminated from the Region;

7.3 by 2007 or earlier, indigenous measles should be eliminated from the Region, and by 2010 the elimination should be certified in every country. Control of disease;

7.4 by 2010 or earlier, all countries should have: • an incidence level for diphtheria of below 0.1 per 100 000 population; • new hepatitis B virus carrier incidence reduced by at least 80% through integration of hepatitis B vaccine in the child immunisation programme; • an incidence level of below 1 per 100 000 population for mumps, pertussis and invasive disease caused by Haemophilus influenzae type b; • an incidence level for congenital syphilis of below 0.01 per 1 000 live births; • an incidence level for congenital rubella of below 0.01 per 1 000 live births.

7.5 by 2015 or earlier: • malaria should in any country be reduced to an incidence level of below 5 per 100 000 population, and there should be no deaths from indigenously-acquired malaria in the Region; • every country should show a sustained and continuing reduction in the incidence, mortality and adverse consequences of HIV infection and AIDS, other sexually transmitted diseases, tuberculosis, and acute respiratory and diar- rhoeal diseases in children.

mass vaccination campaigns. The estimated in Portugal and 61 in Turkey. No cases of mean immunisation coverage in 1998 was neonatal tetanus occurred in Italy during the 94.6% (Figure V.1). period 1984-1996. In the same period, tetanus incidence was still However, immunisation coverage in some Ital- high, accounting for some 100 cases per year: ian areas 1998 was lower than 90%; in addi- in 1997, 105 cases were recorded, with an tion, the percentage of children immunised incidence rate of 1.8 per 1 000 000, one of after their first year of age, that is with some the highest among Western Europe countries delay with respect to the accepted schedule, (Figure V.2). A study conducted in the Marche was also high (ICONA-ISS, in press 1999). Region of Italy (Prospero et al., 1998) showed a raw annual incidence of tetanus of 6.3 per 2.2 Tetanus million population for the period 1992-1995. The standardized incidence for females was The number of new neonatal tetanus cases reg- four times greater than that for males (9.2 istered in 1997 in the WHO European Region and 2.4 per million population annually, were as follows: 2 in Azerbaijan, 1 in Croatia, 2 respectively). This difference may be explained Communicable diseases - 71

by the better protection against tetanus in 2.3 Measles males owing to the vaccination administered during military service as well as by the fact While the target “disease elimination” can that more males do manual work requiring already be considered to have been achieved in compulsory tetanus toxoid vaccination. More- Italy for polio and neonatal tetanus, this does over, the incidence among subjects over 65 not apply to measles. The number of notified years of age was approximately ten times measles cases in Italy is still very high: more greater than that among younger individuals than 30 000 cases were reported in 1996, with (notably no cases were observed in the age an incidence rate of 57 per 100 000, which is group below 30 years); this could be attrib- considerably higher than the mean incidence in uted to the poor immunisation coverage char- Western Europe (Figure V.4). acterising this population group. Vaccination against measles in Italy is recom- Vaccination against tetanus has been manda- mended, but estimated immunisation coverage tory in Italy since 1968. Figure V.3 shows the is still low (56% in 1998), with marked differ- estimated immunisation coverage for the ences among different areas (Figure V.5) Diphtheria-Tetanus vaccine in Italian Regions (ICONA-ISS, in press 1999. This is the worst in 1998 (Italian average 94.8%) (ICONA-ISS, immunisation coverage among all Western in press 1999. European countries (Table V.3) (WHO, 1999c).

Figure V.1: Percentage of two-year-old children immunized against Polio by Italian areas - 1998.

Source: ICONA-ISS, in press 1999. 72 - Communicable diseases

Figure V.2 - Tetanus incidence in EU countries – 1997.

Source: WHO, 1999c.

Figure V.3: Percentage of two-year-old children immunized against Diphtheria-Tetanus by Italian areas – 1998.

ource: ICONA-ISS, in press 1999. Communicable diseases - 73

Figure V.4 - Measles incidence in EU countries. Time trend.

Source: WHO 1999c.

Figure V.5 - Percentage of two-year-old children immunized against measles by Italian areas - 1998.

Source: ICONA-ISS, in press 1999. 74 - Communicable diseases (%) (%) (%) (%) (%) (%) (%) IMMUNIZ. IMMUNIZ. IMMUNIZ. IMMUNIZ. IMMUNIZ. IMMUNIZ. IMMUNIZ. 1990 1991 1992 1993 1994 1995 1996 INCIDENCE COVERAGE INCIDENCE COVERANGE INCIDENCE COVERAGE INCIDENCE COVERAGE INCIDENCE COVERAGE INCIDENCE COVERAGE INCIDENCE COVERAGE Table V.3: Incidence (per 100 V.3: Table of immunization coverage for measles in selected EU countries. 000 population) and percentage AustriaDenmarkFinlandFrance 3.50 -Germany 0.06Greece 82 60 243.82Ireland 3.14 87Italy - 71 - 2.43 0.16 274.91 86Luxembourg 15.87 60Netherlands - 97 77 2.50 76 4.19Portugal 87.52 190.94 9.06 13.44 85 - 0.11 0.10Spain - 80 76 70Sweden 99 3.83 57 2.22 43 60 133.96 4.11 94 0.26United 86.85 40.97 33.40 81Kingdom 0.00 0.75 55.57 0.39 - 78 75 80 85EU average 40 0.34 0.69 50 76.00 99 60 95 5.04 12.23 27.25 2.79 97 114.34 88 4.95 0.04 80 70.40 95 - 62.64 80 3.11 50 - 96 - 93.29 99 0.38 45 87 0.29 75 121.17 94 29.61 85 1.00 - 60 20.29 1.56 2.12 0.12 88 95 - 84.23 62.71 50 3.06 - 99 - 70 - 90 113.06 2.24 10.77 98 34.38 83 - 0.66 94 75 0.25 21.24 - 1.07 8.92 82 50 0.00 30.66 96 - 1.96 - 60 92 83.09 95 - 64.80 70 98 90 - 0.29 94 20.65 32.62 6.53 59.56 - 17.48 0.24 - 50 96 1.19 91 91 75 90 47.42 90 56.81 - 40.29 0.24 - 0.98 - 1.92 94 22.56 50 6.29 - 91 96 6.02 75 0.37 31.47 94 90 13.25 - 0.26 91 94 1.12 12.58 - 92 96 99 90 41.38 0.23 - 92 - 41.95 - - Source: WHO, 1999c. Communicable diseases - 75

3. COMMUNICABLE DISEASES TARGETED 340 000 cases in 1995. In 1996, there were FOR BETTER CONTROL more than 60 000 cases recorded in Italy (incidence rate: 112.9 per 100 000). The same vac- 3.1 Diphtheria cine is used in Italy against Mumps, Measles and Rubella (MMR vaccine) and vaccination is More than 90% of the diphtheria cases reported recommended although not compulsory. world-wide between 1990 and 1995 occurred in the New Independent States (NIS): however, 3.4 Pertussis imported cases of diphtheria have also been documented in Finland, Germany, Norway, Poland The incidence of pertussis is still high in Italy, and elsewhere. In Italy, only one case of diphthe- about 7 per 100 000 population in 1996, when ria per year has been recorded since 1991. 3 895 cases were recorded. Vaccination is voluntary, but the estimated immunisation cover- 3.2 Congenital rubella age in 1998 was quite high (87.9%; range 70.5%-97.6%) in children aged 24 months The reported incidence of congenital rubella (Figure. V.6). syndrome in the European Region has been steadily decreasing in recent years. Only one 3.5 Haemophilus influenzae type B dis- case was recorded in Italy in 1996 (incidence ease rate below 0.01 per 100 000). Rubella, however, is still frequent, with an incidence of 38.2 Vaccination against Haemophilus influenzae per 100 000 in 1996. type B can also prevent invasive forms of diseases, such as meningitis, epiglottitis and pneu- 3.3 Mumps monia. Vaccination is voluntary in Italy and immunisation coverage is very low and uneven- Mumps is still widespread in Europe; 33 coun- ly distributed among Regions, ranging from 1.9 tries of the WHO EURO Region reported some to 41.4 (Figure V.7).

Figure V.6: Percentage of two-year-old children immunized against Pertussis by Italian areas - 1998.

Source: ICONA-ISS, in press 1999. 76 - Communicable diseases

Figure V.7: Percentage of two-year-old children immunized against Haemophilus influenza type B by Italian areas – 1998.

Source: ICONA- ISS, in press, 1999.

Figure V.8: Hepatitis A incidence in EU countries – 1995.

Source: WHO, 1999c. Communicable diseases - 77

3.6 Hepatitis which were recorded in Southern Italy (6 890 cases). A specific analysis of data from the Incidence of all forms of hepatitis is still fairly Sorveglianza Epidemiologica dell’Epatite Virale high in Italy. In 1996, 12 442 cases (2.2 per Acuta (SEIEVA) group (Mele et al., 1997) 100 000) were recorded. Of these, 69.5% were showed that among all cases of hepatitis A type A, while type B accounted for 18.1% of all observed in the period 1986-1994, raw shell- cases (see Table V.1). Reported cases of Hepati- fish consumption was the most frequently tis underestimate the true incidence, in particu- reported risk factor (62%), explaining 42.2% of lar for Hepatitis A, because of under-reporting all Italian cases. Travel to high-medium endem- and subclinical infections. ic areas for people residing in northern and cen- Incidence rates for hepatitis A among EU coun- tral Italy explained a further 24.2% of all acute tries are shown in Figure V.8. France and Italy hepatitis A cases in Italy. show the highest rates. More than 8 600 Incidence of hepatitis B was 3.9/100 000 (2 248 hepatitis A were recorded in Italy in 1996, with cases) in 1996. Although the incidence trend of an incidence rate of 15.1/100 000, 80% of hepatitis B is slowly decreasing, Italy is still

Table V.4: Sexually transmitted disease cases reported in Italy: distribution by type and gender (1991 - 1996).

SEXUALLY MEN WOMEN TOTAL TRANSMITTED DISEASE NUMBER % NUMBER % NUMBER %

Genital warts 9 505 34.2 3 576 21.5 13 081 29.4 Non-specific vaginitis – – 7 992 48.1 7 992 18.0 Non-specific urethritis 5 467 19.6 – – 5 467 12.3 Latent syphilis 2 581 9.3 1 372 8.2 3 953 8.9 Genital herpes 2 669 9.6 766 4.6 3 435 7.7 Chlamydia urethritis 2 173 7.8 – – 2 173 4.9 Gonococcal urethritis 2 059 7.4 – – 2 059 4.6 Pediculosis 1 311 4.7 328 2.0 1 639 3.7 Syphilis I-II (early<2 yrs) 1 117 4.0 327 2.0 1 444 3.2 Molluscum contagiosum 673 2.4 339 2.0 1 012 2.3 Trichonomas vaginitis – – 882 5.3 882 2.0 Chlamydia cervicitis – – 809 4.8 809 1.8 Gonococcal cervicitis – – 135 0.8 135 0.3 Non-specific proctitis 59 0.2 6 0.0 65 0.1 Gonococcal proctitis 54 0.2 7 0.0 61 0.1 PIDa) – – 59 0.3 59 0.1 Chancroid 39 0.1 5 0.0 44 0.1 Lynphogranuloma venereum 36 0.1 6 0.0 42 0.1 Chlamydial proctitis 32 0.1 9 0.0 41 0.1 Gonococcal pharingitis 25 0.0 8 0.0 33 0.1 Granuloma inguinale 4 0.0 2 0.0 6 0.0 Chlamydial pharyngitis 0 0.0 0 0.0 0 0.0

TOTAL 27 810 100 16 628 100 44 438 100 a) Pelvic Inflammatory Diseases.

Source: CESES, 1998. 78 - Communicable diseases

Figure V.9: Hepatitis B incidence in EU countries. Time trend.

Source: WHO, 1999c.

among the Western European countries with known to have died (CESES, 1998). Western the highest rates (Figure V.9). Vaccination Europe still accounts for over 90% of all AIDS against hepatitis B has been mandatory for chil- cases diagnosed in recent years in the WHO dren since 1991, and the estimated immunisa- European Region. In 1997, Spain was the coun- tion coverage observed in 1998 was quite try with the highest incidence rate (119.7 per good, i.e. 95% overall, with only 3 Regions million) followed by Portugal (84.6 per million) with estimated coverage below 90% (Figure and Italy (59.1 per million, 3 381 cases). Finland V.10). In Naples, a metropolitan area of rela- was the country with the lowest incidence rate, tively high HBV endemicity, 2 060 pregnant only 3.6 per million. women admitted for delivery in 1994 to public In recent years, the incidence of AIDS in all or private hospitals were studied to assess the Western European Countries has declined, but prevalence of HbsAg carrier status. HBsAg with different rates: in 1997, as compared to prevalence was 2.5% (Adamo et al., 1998). 1996, for instance, the decrease was 43% in France, 32.8% in Italy, 26% in Spain, 20.2% in 3.7 Acquired Immunodeficiency Syndrome the United Kingdom, and only 2% in Portugal (AIDS) (Figure V.11). The current decline in Western Europe is due, at least partly, to the impact of In the first half of 1998, the cumulative number highly active anti-retroviral treatments which of AIDS cases in the WHO European Region became available in Western Europe in 1996. was 212 138, including 8 063 (3.8%) paediatric A decrease in AIDS incidence rates was cases. About 60% of all reported cases are observed in all three main transmission groups. Communicable diseases - 79

Figure V.10: Percentage of two-year-old children immunized against Hepatitis B by Italian areas – 1998.

Source: ICONA-ISS, in press, 1999.

Heterosexual transmission accounts for an 3.8 Sexually transmitted diseases (STDs) increasing proportion of new AIDS cases (22% in Europe as a whole in 1997 compared with Similar to that observed in other developed 10% in 1990). In several countries, heterosexu- countries, the incidence of gonorrhoea and al contact was the second, or even the first, syphilis, as assessed by the statutory notifica- most important mode of transmission among tions, has fallen in Italy over the last 30 years cases diagnosed in 1997 (Figure V.12). For the (Figure V.14). first time since the start of the epidemic, the This is quite different from that observed in the number of cases infected heterosexually was NIS and CCEE countries, where a sharp increase similar to that among homo-bisexual men of syphilis cases has been reported in recent (CESES, 1998). years (Figure V.15). In Italy, the distribution of incident cases record- During the 1980s, the annual STD notification ed during 1998 shows that the Regions with rates in Italy were between 15 to 50 times lower the highest AIDS incidence rates are Lombardia than those of other European Countries; this may (8.5/100 000), Liguria (9.0/100 000) and Lazio suggest that data from the official notification (7.9/100 000) (Figure V.13) (COA-ISS, 1998a). system has not been accurately reporting the true The number of persons living with HIV or AIDS incidence of the two diseases. A study conduct- at the end of 1998 was estimated to be ed in 1990 examined retrospective data and 500 000 in Western Europe (Houweling et al., compared notified data with cases reported from 1998) and 270 000 in Eastern Europe and cen- selected public centers for STDs; the results con- tral Asian Republics of the former Soviet Union. firmed considerable under-reporting, both for It has also been estimated that 30 000 persons gonorrhea and syphilis. become infected with HIV each year in Western The Italian STD sentinel surveillance system, Europe (CESES, 1998). which has been active since 1991, is the first 80 - Communicable diseases

Figure V.11: AIDS incidence rates in EU countries. Time trend.

Source: WHO, 1999c.

Figure V.12: Percentage of AIDS cases by transmission mode in selected EU countries – 1997.

Source: CESES, 1998. Communicable diseases - 81

Figure V.13: AIDS incidence by Region (cases between October 1997 and September 1998).

Source: COA-ISS, 1998a.

Figures V.14: Statutory notification for gonorrhea and syphilis in Italy. Time trend.

Source: Giuliani et al., 1998. 82 - Communicable diseases

Figure V.15 - Syphilis incidence in subregional groups of countries in the WHO European Region. Time trend

Source: WHO, 1999c.

Figure V.16: Incidence of tuberculosis (all forms) in subregional groups of countries in the WHO European Region. Time trend.

Source: WHO, 1999c. Communicable diseases - 83

standardized epidemiological project in Italy for treatment) makes disease control more difficult. collecting national data on the full spectrum of Probably, HIV infection also plays a certain role STDs. After six years of surveillance activity, the in reducing certain people’s resistance to tuber- characteristic of the network, the population of culosis (WHO, 1998b); however, poverty, cases, and the number of reported cases have including poor housing, malnutrition and sub- remained stable and consistent. stance abuse, are likely to be the most impor- Table V.4 reports the distribution of STD cases tant factors (WHO, 1999b). reported to the STD Surveillance System in Italy In Italy, under-reporting of this still frequent between January 1991 and December 1996. disease (Buiatti et al., 1998) makes it particu- Genital warts, non-specific genital infections larly difficult to interpret the incidence time (non-gonococcal non-chlamydia infections), trend. An increase in incidence in recent years latent syphilis and genital herpes were the most could, in fact, be due either to a true increase frequently detected SDTs. Other common ven- in the number of cases or to a greater number eral diseases, such as gonorrhea and syphilis, of cases notified. In Italy, the incidence in 1996 are reported as 7th and 9th, respectively. was 2.6/100 000 (1 490 notified cases) for the Monthly figures did not change significantly in extra-pulmonary forms and 7.02 per 100 000 Northern or Central Italy; however, some vari- (4 022 notified cases) for the pulmonary ability was observed in Southern Italy during forms. the last three years. The only trends observed were a moderate increase in the cases of Mol- 3.10 Malaria luscum contagiosum and Pediculosis pubis in the years between 1993 and 1995. The mini- In the European Region, some countries are mal incidence for the commonest diseases was recently experiencing a resurgence of malaria; determined using the number of cases reported the majority of cases recorded in 1997 are from annually. During the study period, the incidence Turkey (35 456), Tajikistan (29 848) and Azer- ranged between 3.4 and 4.1 per 100 000 for baijan (9 909) (Figure V.17). genital warts, 5.0 and 6.0 per 100 000 for non- Among the Western Europe countries, Italy has specific vaginitis, and 2.8 and 3.3 per 100 000 the highest incidence rates of malaria. Howev- for non-specific urethritis. er, from 1986 to 1996, only imported and occa- Large differences were observed in the frequen- sional cryptic cases of malaria (due to infected cy of diagnoses between non-Italians and Ital- blood transfusions or the inadvertent carriage ians. Higher proportions of STD cases with gono- of infected tropical mosquitoes by aeroplanes coccaal urethritis (14.3% vs. 3.8%) and latent and containers or syringe-sharing between syphilis (15.8% vs. 9.7%) as well as a lower pro- drug addicts) have occurred in Italy. Among the portion of cases of genital warts (18.4% cases occurring in 1997 (816, of which 10 have vs.32.3%) were observed among non-Italians. died), it was argued that one case of “introduced malaria” was transmitted by an Italian 3.9 Tuberculosis indigenous Anopheles labranchiae (Baldari et al., 1998). In many countries in the Eastern part of the The total number of malaria cases registered in WHO European Region, the incidence of TBC Italy in the period 1993-1997 is summarised in has been increasing over recent years (Figure Table V.5. Plasmodium falciparum accounted V.16). for 75.4% of total infections. The highest num- The downward trend of TBC incidence in West- ber of cases was imported from Africa (85.6%), ern Europe has levelled off. The spread of followed by Asia, America and Oceania. The Mycobacterium tuberculosis resistance to incidence rate in 1993 increased in 1997 from chemotherapy (often linked to inappropriate 1.17 to 1.42 per 100 000 population. 84 - Communicable diseases

Table V.5: Cases of Malaria (number and incidence per 100 000 population) in Italy between 1993 and 1997, and percentage of cases by purpose of travel.

YEARS TOTAL INCIDENCE % OF CASES BY PURPOSE OF TRAVEL NUMBER RATE JOB TOURISM FOREIGNERS MISSIONARY UNKNOWN OF CASES (X 100 000)

1993 668* 1.17 29.6 26.8 35.0 5.2 3.0 1994 782** 1.37 31.2 24.7 22.1 4.9 17.1 1995 743 1.30 25.4 27.2 26.0 10.2 11.1 1996 760 1.33 23.6 22.2 35.9 5.1 13.2 1997 816*** 1.42 20.6 23.2 35.4 3.4 17.2

∗ among these, 2 autochthonous cases due to “accidental” causes. ∗∗ among these, 3 autochthonous cases (one due to syringe sharing, one to transfusion and one of unknown cause). ∗∗∗ among these, 2 autochthonous cases (one due to “accidental” inoculation and one of “introduced malaria”).

Source: Ministry of Health of Italy, 1999.

Figure V.17: Resurgence of Malaria in the WHO European Region – 1997.

Source: WHO-EURO, 1998. Communicable diseases - 85

3.11 Influenza important implications in terms of population health and costs for the public health system. At present, acute respiratory infections, in par- Changes in population habits as well as the ticular influenza epidemics, represent the prin- extent of national and international trade in cipal cause of morbidity among both children food items have dramatically changed the pic- and adults, especially the elderly. However, no ture which public health authorities face when statistical data are routinely available. Acute having to address food safety matters. Tradi- respiratory infections cause a considerable tional food control and monitoring systems are number of absences from school and work, as no longer fully adequate to respond to these well as a significant burden for the health care new situations, which need innovative system. In Italy the number of units of flu vac- approaches to be able to promptly recognise cine sold between 1994 and 1998 varied from the causes of foodborne diseases and establish 2 241 in 1996 to 3 735 in 1998, with no clear effective preventive policies. time trend. Estimates of immunisation coverage Among the routinely monitored communicable for people aged 65 years or above do not diseases in Italy, there is a significant proportion exceed the rate of 23.2%1 in 1996. Under this transmitted by food, such as Salmonella infec- best possible scenario, an immunisation cover- tions and botulism. The cases of human salmo- age of 95 %, as proposed by the WHO Health nellosis reported from 1984 to 1996 in Italy have 21 policy, could be achieved only if an increase increased since 1984 reaching a peak value of of at least 71.7 % in the use of flu vaccine on 23 348 in 1992 (WHO-FAO, 1995). However, as the elderly occurs. major under-reporting is suspected, these variations as well as those recorded among geo- 3.12 Foodborne infections graphical Regions within the country may mainly reflect the degree of differential reporting. As Recent data confirm an increase in foodborne far as hepatitis A is concerned, the data are diseases in many countries. Zoonoses due to reported in Section 3.6. newly identified pathogens have produced a major impact in recent years. A new variant of CJD has emerged in the UK in association with 4. ANTIBIOTIC RESISTANCE Bovine Spongiform Encephalopathy (BSE) through largely unknown pathophysiological All available evidence points to an increase in mechanisms. Other new pathogens which the prevalence of drug resistance among bacte- emerged in the last few decades have caused a ria, which has paralleled the expansion of significant impact, including Campylobacter, antibiotic uses. Particularly difficult manage- Yersinia and Listeria. In a recent overview of the ment problems are now posed by certain bac- environmental health situation in Europe car- terial species, which are able to acquire resis- ried out by the WHO European Centre for Envi- tance to the majority of available antibiotic ronment and Health, it was estimated that each agents. Thus, the increasing prevalence of resis- year 130 million Europeans (about 15% of the tance to antibiotics among pathogenic micro- total population of the WHO European Region) organisms, and particularly among bacteria, is are affected by episodes of foodborne diseases, now a major problem and one which has seri- ranging from mild gastrointestinal infections to ous implications for the treatment and preven- severe gastro-enteritis and even death in tion of infectious diseases (EU Scientific Steering extreme cases (WHO-FAO, 1995). This has Committee, 1999). Here are some examples:

1 Assuming that all the vaccines are used for people aged above 65 years. However, a large part of doses are used within the National Health System to vaccinate health personnel and another share for children. 86 - Communicable diseases

Penicillin resistance (Pradier et al., 1997) has a More than 20% of patients admitted to inten- high prevalence in Spain (45%) and France sive care units throughout Europe develop an (25%); rates between 5 to 10% have been acquired infection (Vincent et al., 1995). In a reported in the UK, Germany, Belgium and Italy, comparison between countries of the incidence and most of these strains are moderately resis- of antimicrobial resistance among aerobic Gram- tant. There have been recent reports of moder- negative bacilli from patients in Belgium, France, ately penicillin-resistant Streptococcus pneumo- Portugal, Spain and Sweden, the highest rate of niae with high-level resistance to cefotaxime resistance was seen in all countries among and ceftriaxone in the United States (Coffey et Pseudomonas aeruginosa (up to 37% resistant al., 1995). Many of these penicillin-insuscepti- to ciprofloxacin in Portugal and 46% resistant to ble strains are co-resistant to non-beta-lactam gentamicin in France), Enterobacter species, agents. High rates of macrolide resistance have Acinetobacter species, and Stenotrophomonas been reported in Spain (18%), France and Bel- maltophilia, and in Portugal and France among gium (30%) (Pradier et al., 1997; Campbell et Klebsiella species (Jarlier et al., 1996; Hanberger al., 1998). et al., 1999). Ciprofloxacin resistance was higher While Streptococcus pyogenes remains highly among Enterobacter spp from Belgium (31%), susceptible to beta-lactam antibiotics, high France (20%) and Portugal (21%). rates of erythromycin resistance have been In a European study, 26% (Sweden) to 48% (Por- reported in Finland (20%), the UK (23%), Italy tugal) of Enterobacter cloacae isolates showed (81%) and Spain (19%) (Borzani et al., 1997; decreased susceptibility to caftazidime (Archibald Garcia-Bermejo et al., 1998). et al., 1997). Previous use of third generation Neisseria meningitidis strains with decreased cephalosporins has also been associated with the susceptibility to penicillin (MIC > 0.16 to 1.28 selection of resistance to beta-lactams in blood mg/L) have been reported world-wide, but with isolates of Enterobacter spp, which is associated variable frequency. with higher mortality (Livermore, 1995). Fluoroquinolone resistance among Campylobac- Methicillin-resistant Staphylococcus aureus ter has been reported to be over 50% by sever- was increased in frequency since the 1970s in al investigators (Piddock, 1995; Hoge et al., most countries except Scandinavia and the 1998) and has been correlated with bacteriolog- Netherlands (Vincent et al., 1995; Voss et al., ical and clinical failures (Petruccelli et al., 1992). 1994). Escherichia coli is responsible for more than Although much scientific information is avail- 80% of acute uncomplicated cystitis in young able, not all aspects of the development of women. Increased resistance to several antimi- antibiotic resistance are well understood. It is, crobials, including ampicillin, trimethoprim- however, known that resistant bacteria are sulphonamide and trimethoprim, has been actually selected and disseminated by the use reported in the UK and a significant increase in of antibiotics. Thus one important preventive the number of Escherichia coli which are resis- measure would be a much more prudent use of tant to fluoroquinolones has been documented antibiotics in all sectors (EU Scientific Steering elsewhere (Threlfall, 1997) Committee, 1999). CHAPTER VI

EXTERNAL CAUSES OF MORTALITY AND DISABILITY

CONTENTS

1. CHILDHOOD AND YOUTH ...... 88 1.1 Road accidents (ICD IX E800-E848) ...... 95 1.2 Violent causes (ICD IX E950-E999 ...... 95 1.3 Other external causes (ICD IX E850-E949) ...... 95

2. ADULTS ...... 100 2.1 Road accidents ...... 103 2.2 Domestic and leisure accidents ...... 105 2.3 Accidents at work ...... 106 2.4 Violent causes ...... 107 88 - External causes of mortality and disability

TARGET 4 - HEALTH21

By the year 2020, young people in the Region should be healthier and better able to fulfil their roles in society.

In particular: 4.1 children and adolescents should have better life skills and the capacity to make healthy choices; 4.2 mortality and disability from violence and accidents involving young people should be reduced by at least 50%; 4.3 the proportion of young people engaging in harmful forms of behaviour such as drug, tobacco and alcohol consumption should be substantially reduced1; 4.4 the incidence of teenage pregnancies should be reduced by at least one third2.

External causes of death and disability include similar for both sexes (0.78 and 0.80 per accidents in the social environment and at 100 000, respectively, for males and females). work, natural and man-made disasters, poi- sonings, misadventures whilst in medical care A marked difference can be observed in mor- and violence. tality rates (per 100 000) for external causes among children and adolescents in the Euro- pean sub-Regions. In particular, a consistent 1. CHILDHOOD AND YOUTH East-West gap can be observed for both sexes and all the age groups and for different specif- In 1994, deaths due to external causes (ICD IX ic external causes (LSHTM/WHO, 1998) (Figures E800-E999) (e.g. accidents and violence) repre- VI.2a and VI.2b to VI.5a and VI.5b). sented 4.0% of all deaths in Italy in the age range 0-4 years, whereas in the first year of life Nevertheless, accidents and violence remain they represented 1.6% (ISTAT, 1997c). Age- among the most important causes of mortality specific death rates from all external causes in for both males and females in the European EU countries for females and males in the age Union as far as the age group 0-19 is con- group 0-4 are shown in Figures VI.1a and VI.1b cerned.. Rates range from 11.3 in Sweden to (WHO, 1996b). From these figures it can be 34.6 per 100 000 in Portugal for males, and seen that among the EU countries, Italy has one from 5.3 in the Netherlands to 13.6 per of the lowest mortality rates for males and is in 100 000 in Portugal for females (WHO, 1996b) the mid-range for females. The rates are very (Figures VI.6a and VI.6b).

1 See Chapter VII. 2 See Chapter III. External causes of mortality and disability - 89

Figures VI.1a: Age specific death rate for all external causes in EU countries. Age group 0-4. Females. Last available year.

Source: WHO, 1996b.

Figures VI.1b: Age specific death rate for all external causes in EU countries. Age group 0-4. Males. Last available year.

Source: WHO, 1996b. 90 - External causes of mortality and disability

Figure VI.2a: Mortality rate for external causes by category in subregional groups of countries in the European Region. Age group 1-4. Females. 1992-1993.

Source: WHO, 1996b.

Figure VI.2b: Mortality rate for external causes by category in subregional groups of countries in the European Region. Age group 1-4. Males. 1992-1993.

Source: WHO, 1996b. External causes of mortality and disability - 91

Figure VI.3a: Mortality rate for external causes by category in subregional groups of countries in the European Region. Age group 5-9. Females. 1992-1993.

Source: WHO, 1996b.

Figure VI.3b: Mortality rate for external causes by category in subregional groups of countries in the European Region. Age group 5-9. Males. 1992-1993.

Source: WHO, 1996b. 92 - External causes of mortality and disability

Figure VI.4a: Mortality rate for external causes by category in subregional groups of countries in the European Region. Age group 10-14. Females. 1992-1993.

Source: WHO, 1996b.

Figure VI.4b: Mortality rate for external causes by category in subregional groups of countries in the European Region. Age group 10-14. Males. 1992-1993.

Source: WHO, 1996b. External causes of mortality and disability - 93

Figure VI.5a: Mortality rate external causes by category in subregional groups of countries in the European Region. Age group 15-19. Females. 1992-1993.

Source: WHO, 1996b.

Figure VI.5b: Mortality rate for external causes by category in subregional groups of countries in the European Region. Age group 15-19. Males. 1992-1993.

Source: WHO, 1996b. 94 - External causes of mortality and disability

Figure VI.6a: Age specific death rates for external causes in age group 0-19 years in EU countries. Females. Last available year.

Source: WHO, 1996b.

Figure VI.6b: Age specific death rates for external causes in age group 0-19 years in EU countries. Males. Last available year.

Source: WHO, 1996b. External causes of mortality and disability - 95

Italy has one of the highest rates for accidental 1.2 Violent causes (ICD IX E950-E999) death in males among the EU countries (23.28 per 100 000 for males in 1993). In 1994, in the Deaths from violent causes in childhood (1-14 age range 0-19 years, 1 725 people died due to years) are more common in the NIS and Baltic external causes, i.e. 1 306 males and 419 countries than in Western countries (Table females (ISTAT, 1997c). VI.2). Deaths due to external causes may be broken Very low death rates for violent causes in both down into a number of categories. sexes are reported in Southern European countries, including Italy. 1.1 Road accidents (ICD IX E800-E848) 1.3 Other external causes (ICD IX E850- Road accidents (mainly motor vehicle accidents) E949) do not play the main role in explaining the East- West mortality gap among European countries, The East-West differences from external causes although there are considerable differences as a whole mainly stem from the group of between sub-Regions, particularly under the “other external causes, excluding violence” age of 10 years (Table VI.1). For each age (see Table VI.3), such as drowning, accidental group, and particularly between 15 and 19 poisoning, fire, falls and misadventures whilst in years, the male mortality rates are consistently medical care (Figures VI.7a-b, VI.8a-b, VI.9a-b, higher if compared to those of females. VI.10a-b).

Table VI.1: Mortality rates (per 100 000) from road accidents by age, sex and sub-Region - 1992-1993.

AGE RANGE 1-4 5-9 10-14 15-19

GEOGRAPHICAL AREA MALE FEMALE MALE FEMALE MALE FEMALE MALE FEMALE Southern NIS 8.6 5.2 10.7 5.4 6.1 2.7 12.2 4.1 North-West NIS 7.3 5.4 12.6 6.6 10.2 4.7 34.7 14.5 Baltic Countries 7.6 6.2 14.6 7.7 12.5 5.9 39.0 14.5 South-East Europe 8.9 5.4 10.4 6.6 6.5 3.4 15.8 6.3 Central Europe 6.0 4.5 6.8 4.4 6.4 4.0 30.7 9.2 Southern Europe* 4.0 3.5 4.4 2.6 5.6 3.0 40.0 10.7 Western Europe 3.1 2.7 4.0 2.1 4.7 3.2 29.3 10.1 Scandinavia 2.8 1.7 3.5 1.9 4.5 2.5 22.9 7.4

*including Italy, Greece, Spain and Portugal Source: WHO, 1996b.

Table VI.2: Mortality rates (per 100 000) from violence by age, sex and sub-Region - 1992-1993.

AGE RANGE 1-4 5-9 10-14 15-19

GEOGRAPHICAL AREA MALE FEMALE MALE FEMALE MALE FEMALE MALE FEMALE Southern NIS 5.3 3.8 3.3 1.9 9.8 2.9 36.5 12.7 North-west NIS 2.9 2.7 2.6 1.7 10.0 3.7 63.3 17.7 BalticCountries 3.0 0.9 1.9 1.0 7.9 2.2 47.7 12.2 South-east Europe 1.1 1.2 1.1 0.6 3.6 0.9 15.5 5.0 Central Europe 1.2 1.1 0.7 0.4 3.2 0.8 17.7 4.8 Southern Europe* 0.7 0.5 0.8 0.3 1.6 0.5 6.7 2.4 Western Europe 1.6 1.2 0.8 0.4 2.2 1.1 12.2 4.3 Scandinavia 0.6 0.6 1.1 0.7 2.0 1.5 16.0 5.7

* Including Italy, Greece, Spain and Portugal Source: WHO, 1996b. 96 - External causes of mortality and disability

Figure VI.7a: Mortality rate for “other” external causes in subregional groups of countries in the European Region. Age group 1-4. Females. 1992-1993.

Source: WHO, 1996b.

Figure VI.7b: Mortality rate for “other” external causes in subregional groups of countries in the European Region. Age group 1-4. Males. 1992-1993.

Source: WHO, 1996b. External causes of mortality and disability - 97

Figure VI.8a: Mortality rate for “other” external causes in subregional groups of countries in the European Region. Age group 5-9. Females. 1992-1993.

Source: WHO, 1996b.

Figure VI.8b: Mortality rate for “other” external causes in subregional groups of countries in the European Region. Age group 5-9. Males. 1992-1993.

Source: WHO, 1996b. 98 - External causes of mortality and disability

Figure VI.9a: Mortality rate for “other” external causes in subregional groups of countries in the European Region. Age group 10-14. Females. 1992-1993.

Source: WHO, 1996b.

Figure VI.9b: Mortality rate for “other” external causes in subregional groups of countries in the European Region. Age group 10-14. Males. 1992-1993.

Source: WHO, 1996b. External causes of mortality and disability - 99

Figure VI.10a: Mortality rate for “other” external causes in subregional groups of countries in the European Region. Age group 15-19. Females. 1992-1993.

Source: WHO, 1996b.

Figure VI.10b: Mortality rate for “other” external causes in subregional groups of countries in the European Region. Age group 15-19. Males. 1992-1993.

Source: WHO, 1996b. 100 - External causes of mortality and disability

Table VI.3: Mortality rates (per 100 000) from other external causes by age, sex and sub- Region - 1992-1993.

AGE RANGE 1-4 5-9 10-14 15-19

SUB-REGION MALE FEMALE MALE FEMALE MALE FEMALE MALE FEMALE

Southern NIS 61.5 49.7 20.6 11.0 17.5 8.0 26.5 9.0 North-West NIS 39.8 27.7 27.0 11.0 22.3 7.9 47.7 12.2 Baltic Countries 47.1 26.3 24.6 8.1 21.1 8.1 46.5 6.3 South-East Europe 34.8 25.4 18.7 7.7 18.4 6.4 28.8 7.5 Central Europe 11.4 7.5 5.8 2.3 6.1 1.7 15.1 3.3 Southern Europe* 6.8 4.5 3.2 1.4 3.7 1.6 10.6 2.1 Western Europe 7.2 4.2 2.9 1.7 2.7 1.1 6.8 1.8 Scandinavia 4.9 2.9 5.3 0.9 2.3 0.8 6.9 2.3

* Including Italy, Greece, Spain and Portugal Source: WHO, 1996b.

This group of external causes shows much dents. In Italy, there are 500-600 deaths per year more pronounced differences between the due to drowning, especially in young males. Western and the CCEE and NIS countries than Permanent paralysis may occur as a result of mortality from either motor vehicle accidents or diving into a body of water or swimming pool. violence does. For example, if compared to A recreationally acquired spinal cord injury nor- Sweden, rates in the Baltic countries, such as mally results in quadriplegia. The number of Latvia, are 5 times higher for motor vehicle traf- spinal injuries sustained as a result of swimming fic deaths, but 9 times higher for other external accidents does not appear to be widely pub- causes. This group of external causes in the lished. However, estimates made by WHO CCEE and NIS countries, however, becomes (Murray et al., 1996) indicate an incidence rate proportionally less important with the progres- by area of the world ranging from 0.1 per sion of age, as deaths from violence become 100 000 in the “Established Market Eco- more important. nomies” to 1.5 per 100 000 in sub-Saharan As for drowning, data suggest that throughout Africa. On the basis of these data, it can be esti- the Region males are more likely to drown than mated that about 50 or 60 cases per year of females. The higher consumption of alcohol by spinal injury resulting in tetraplegia occur in males is suggested as one contributing factor to Italy as a consequence of inappropriate use of this. Private pools, lakes and other freshwater recreational waters by both young and adult bodies contribute significantly to drowning sta- people. tistics, especially in children - in Denmark 63% of all child (0-14 years old) deaths from drowning occurred in such water bodies between 2. ADULTS 1989 and 1993. This trend is clearly illustrated by data from the UK where the greatest per- In the adult age range, external causes are a centage of drowning occurs in such open water major cause of death in the European Region bodies. In terms of all accidental deaths in the and the second leading contribution to the European Region, drowning accounts for less East-West mortality gap (WHO, 1999c) (Figure than 10% of the 280 000 deaths due to acci- VI.11). External causes of mortality and disability - 101

TARGET 9 – HEALTH21

By the year 2020, there should be a significant and sustainable decrease in injuries, disability and death arising from accidents and violence in the Region.

In particular: 9.1 mortality and disability from road accidents should be reduced by at least 30%. 9.2 mortality and disability from all work, domestic and leisure accidents should be reduced by at least 50%, with the largest reductions in countries with current high levels of mortality from accidents. 9.3 the incidence of and mortality from domestic, gender-related and organized violence and its health consequences should be reduced by at least 25%.

Figure VI.11: Standardized death rate for external causes in subregional groups of countries in the WHO European Region. Time trend.

Source: WHO, 1999c. 102 - External causes of mortality and disability

In 1995, the mortality ratio from all external there is also in this case a significant North- causes in Western Europe, the CCEE and NIS South gradient in Italy (Figure VI.13). Howev- was about 1:2:4. The homicide rates in these er, due to the marked decrease in mortality in sub-Regions had an even more skewed ratio Northern Italy over the last years, in 1994 the (about 1:3:20) (Table VI.4). Italian main geographic areas showed much There is an overall decrease in mortality due closer rates. The peak in deaths observed in to external causes in Western Europe. In Italy, 1980, especially among females, can be the overall rate (40.7 per 100 000) is lower accounted for by the deaths resulting, from than the EU average (WHO, 1999c) (Figure the earthquake in the Irpinia area (Southern VI.12). Regarding other causes of death, Italy).

Table VI.4: Main external causes of death (rate per 100 000) and percentage of total external deaths in groups of countries – 1995.

GROUP OF COUNTRIES EU CCEE NIS DEATH % ALL DEATH % ALL DEATH % ALL CAUSE OF DEATH RATE PER EXT. RATE PER EXT. RATE PER EXT. 100.000 CAUSES 100.000 CAUSES 100.000 CAUSES Road transport accidents 11.8 27 15.7 20 19.8 10 Suicide 11.7 26 16.1 21 30.8 17 Homicide 1.2 3 3.3 4 23.8 13 Other causes 19.6 44 43.3 55 112.1 60 All external causes 44.0 100 78.0 100 186.0 100

Source: WHO, 1998b.

Figure VI.12: Standardized death rate for external causes in EU countries. Time trend.

Source: WHO, 1999c. External causes of mortality and disability - 103

Figure VI.13: Standardized death rate by gender for external causes in different areas of Italy. Time trend.

Source: data provided by ISS, 1999, unpublished.

2.1 Road accidents Death rates for road accidents also show a slowly decreasing trend in several Western The annual average number of reported road European countries (Figure VI.14), accidents causing injury amounts to about 340 In Italy, data for road accidents, injuries and per 100 000 in the EU countries; this is 2-3 deaths from 1980 to 1997 indicate a small times higher than the averages in the CCEE and increasing trend in accidents and injuries NIS. However, as far as mortality is concerned, observed from the late 1980’s (Table VI.5). In the situation is the reverse, due to the higher 1997, there were 190 031 accidents and a fatality rate in Eastern Europe (WHO, 1999b). total of 270 962 persons were injured, i.e. Overall, the total number of road accidents in around 4.7 in 1 000 people per year. The the EU countries has been decreasing over the Northern part of Italy showed the highest last 14 years (-10.2%), despite the increase mortality rates for traffic accidents (Table VI.6), recorded in traffic volume. However, an oppo- although in the South of Italy death rates site trend was observed in a few countries, showed the largest increase between 1988 namely Greece, Ireland, Spain and Portugal. and 1992. 104 - External causes of mortality and disability

Figure VI.14: Standardized death rate for traffic accidents in EU countries. Time trend.

ource: WHO, 1999c.

Table VI.5: Road Accidents (Rates per 1 000 vehicles, number of persons injured and deaths) in Italy between 1980 and 1997.

ROAD TRAFFIC ACCIDENTS YEAR NUMBER RATE/ 1 000 INJURIES DEATHS VEHICLES 1980 163 770 6.9 222 873 11 081 1981 165 721 6.7 225 242 10 450 1982 159 858 6.1 217 426 9 988 1983 161 114 5.8 219 744 9 918 1984 159 051 5.6 217 552 9 202 1985 157 786 5.2 216 102 9 151 1986 155 427 4.9 213 159 9 423 1987 158 208 4.8 217 511 9 066 1988 166 033 4.9 228 186 8 952 1989 160 828 4.6 216 329 8 724 1990 161 782 4.5 221 024 9 208 1991 170 702 4.6 240 688 9 606 1992 170 814 4.5 241 094 9 645 1993 153 393 4.3 216 100 8 623 1994 170 679 4.8 239 184 8 379 1995 182 761 5.1 259 571 n.a. 1996 190 068 5.2 272 115 n.a. 1997 190 031 5.1 270 962 n.a

n.a. = not available. Source: ISTAT, 1997e. External causes of mortality and disability - 105

Table VI.6: Mortality Rates (per 100 000 residents) due to road accidents in Italy by Region.

YEAR REGION DIFF. (%) 1988 1992 Piemonte 18.72 20.92 11.75 Valle d’Aosta 25.55 22.31 –12.68 Liguria 11.56 10.95 –5.28 Lombardia 17.80 18.17 2.08 Trentino 16.15 17.90 10.84 Veneto 20.69 22.04 6.52 Friuli Venezia Giulia 20.19 19.74 –2.23 Emilia Romagna 23.65 24.88 5.20 Marche 19.94 17.81 –10.68 Toscana 16.30 16.64 2.09 Umbria 16.08 17.83 10.88 Lazio 15.27 15.91 4.19 Campania 8.84 9.45 6.90 Abruzzo 14.30 14.53 1.61 Molise 12.73 14.80 16.26 Puglia 13.59 16.95 24.72 Basilicata 12.11 12.28 1.40 Calabria 8.78 10.86 23.69 Sicilia 9.39 11.02 17.36 Sardegna 15.56 15.88 2.06

North 19.02 19.95 4.89 Centre 16.28 16.54 1.60 South 10.92 12.44 13.92

ITALY 15.57 16.57 6.42

Source: Ministry of Health of Italy, 1996.

2.2 Domestic and leisure accidents requests for emergency medical care and about 420 000 in-patient admissions.(Ministry of Safety at home and during leisure activities is an Health of Italy, 1996). The risk increases consid- important public health issue; every year in erably with the average amount of time spent Europe, 45 people per 1 000 are estimated to at home: compared to men, women are twice have at least one accident at home or during as likely to have an accident; the rates are also leisure time, that is to say ten times more peo- relatively high for children and prove the high- ple than those injured in road accidents (WHO, est among old people (ISTAT, 1994b). A similar 1998c). picture emerges from a comparative study car- In Italy, a national survey of domestic accidents ried out in the EU countries, in which an analy- estimated about 3 300 000 incidents a year sis was carried out of all cases treated, through Hospital Emergency admissions records showed a sample of health care services in each country that there were about 3 500 000 estimated between 1990 and 1992. According to this 106 - External causes of mortality and disability

study, accidents at home accounted for the 100 000 residents, 10.3 and 16.9 in men and biggest portion of all accidents recorded in Italy, women, respectively (Table VI.7)]. The highest with a much higher proportion than the EU death rates are observed among people aged average across all age groups (EHLASS, 1995). 70 years or more. In 1992, there were 7 779 deaths due to Data regarding drowning are summarized in domestic accidents [(13.7 average deaths per Section 1.3.

Table VI.7: Mortality rates (per 100 000 residents) due to domestic accidents in Italy by Region.

YEAR REGION DIFF. (%) 1988 1992 Piemonte 17.73 18.66 5.25 Valle d’Aosta 13.22 11.15 –15.66 Liguria 20.79 22.97 10.49 Lombardia 12.06 12.55 4.06 Trentino 13.87 13.20 –4.83 Veneto 10.26 11.17 8.87 Friuli 18.44 20.49 11.12 Emilia Romagna 11.56 10.88 –5.88 Marche 13.81 16.42 18.90 Toscana 19.21 17.80 –7.34 Umbria 13.86 16.60 19.77 Lazio 14.35 15.64 8.99 Campania 7.55 9.29 23.05 Abruzzo 15.19 15.41 1.45 Molise 15.45 19.33 25.11 Puglia 7.96 11.11 39.57 Basilicata 11.95 13.75 15.06 Calabria 10.22 11.49 12.43 Sicilia 10.66 11.84 11.07 Sardegna 13.05 14.48 10.96 North 13.61 14.17 4.11 Centre 15.83 16.51 4.30 South 9.82 11.57 17.82 ITALY 12.66 13.68 8.06

Source: Ministry of Health of Italy, 1996.

2.3 Accidents at work nized (Geddes, 1995) and there may be considerable delays between reporting and The incidence rates of recognized occupation- recognition. al diseases attracting disablement benefits Data on occupational accidents and diseases provide a rough estimate of incidence and are not comparable among countries: they prevalence, although such figures are general- can reflect variations in notification and reg- ly lower than the actual number of cases. istration practices rather than real differ- Generally speaking, in Italy only a small pro- ences in rates. In the European OECD coun- portion of reported cases are officially recog- tries, about 10% of registered occupational External causes of mortality and disability - 107

accidents resulting in personal injury are 2.4 Violent causes graded as severe, with more than 60 days of leave of absence, and 1-5% of all registered Intentional and unintentional violence is respon- occupational accidents lead to permanent sible for huge social and economic costs and is disability. a major cause of death. In fact, violence at Physical workload and musculoskeletal strain home is often a hidden problem, because it is from working conditions still affect 10-30% of either seldom acknowledged by the victim or the workforce in highly industrialized coun- the perpetrators, or included in accident statis- tries. tics. Violence at home is mainly, but not always, According to ILO data (International Labour a gender-based problem. Twenty per cent of all Office, 1994), about 1 940 people died in Italy women in Europe have been a victim of violence from work-related accidents in 1991 (3.4 per at least once in their lives, most often from 100 000 population) and almost one million someone they know. In industrialised countries, were injured. While the rate of injuries is the domestic violence has been reported to cause same as the EU average, the death rate is high- more injuries to women than rape, traffic acci- er (Figure VI.15). dents and muggings combined. Another impor- Data from ISPESL for 1994-1997 (Table VI.7 and tant issue is the abuse of elderly people and Figure VI.16) indicate a decrease in the number people with mental health problems, particular- of reported occupational accidents and disabil- ly those in institutions. Socially motivated vio- ities, whereas no clear time-trend emerges for lence against refugees and ethnic groups has lethal cases. also been seen to be on the increase. Economic loss from occupational accidents and Violence against women has, in general, received injuries in some EU countries is calculated to limited attention as a public health issue. range from 3 to 5% of the GDP. In the United Although data on the occurrence and type of Kingdom, for example, the cost of personal such violence are scarce, recent World Bank esti- injuries from work accidents and work-related mates indicate that in the established market illnesses is estimated to be about 5-10% of the economies, gender-based victimisation is respon- gross trading profit of all National companies sible for the loss of one out of five healthy days by (WHO, 1999b). women of reproductive age (Heise, 1994).

Table VI.8: Impact on health of occupational accidents in Italy by sector and gender - 1994-1997a.

AGRICULTURE INDUSTRY TEMPORARY PERMANENT DEATH TEMPORARYY PERMANENT YEAR DEATH TOTAL DISABILITY DISABILITY DISABILITY DISABILITY

MALES FEMALES MALES FEMALES MALES FEMALES MALES FEMALES MALES FEMALES MALES FEMALES 1994 71 879 29 019 4 663 1 902 157 10 483 106 78 281 22 141 2 451 936 58 694 603 1995 66 130 25 296 4 321 1 696 161 6 464 054 75 747 21 055 2 212 969 64 661 711 1996 61 537 23 592 4 062 1 685 159 11 448 176 78 232 20 332 2 248 934 65 641 033 1997 47 249 18 747 3 394 1 264 134 6 429 428 80 628 19 885 2 338 999 75 604 117 a It does not include disabilities for periods shorter than 4 days and data concerning some categories of workers not covered by compulsory insurance. Source: ISPESL, based on INAIL data, 1999. 108 - External causes of mortality and disability

Figure VI.15: Occupational accident mortality in EU countries - 1991-1993.

Source: ILO, 1994.

Figure VI.16 – Frequency of accidents at workplace in Italy. Time trend*.

Source: ISPESL, based on INAIL data, 1999. * For agricultural workers a change in the definition of the accidents occurred in 1993 explaining the large drop observed in 1993 and 1994. CHAPTER VII

HEALTH DETERMINANTS: NUTRITION, LIFESTYLE, PHYSICAL ENVIRONMENT AND HUMAN SETTLEMENTS

CONTENTS 1. NUTRITION ...... 110 1.1 Healthy diet ...... 110 1.2 Obesity ...... 112 1.3 Breast-feeding ...... 115 2. LIFESTYLE ...... 116 2.1 Physical activity ...... 116 2.2 Tobacco ...... 116 2.3 Alcohol ...... 123 2.4 Psychoactive drugs ...... 128 2.5 Safe sex ...... 130 3. PHYSICAL ENVIRONMENT AND HUMAN SETTLEMENTS ...... 130 3.1 Air pollution ...... 131 3.2 Electromagnetic fields ...... 138 3.3 Water ...... 139 3.4 Waste generation, collection and treatment ...... 144 3.5 Noise ...... 147

4. HUMAN SETTLEMENTS ...... 148 110 - Health determinants: Nutrition, lifestyle, physical environment and human settlements

1. NUTRITION pean Region until 1990, after which there was a gradual decline, due essentially to a reduction 1.1 Healthy diet in fat consumption by people in the NIS and CCEE (Figure VII.1). Food choice is an important determinant for In the EU countries, the percentage of total health. All WHO Member States have endorsed energy obtained from fat has increased slightly the World Health declaration and Plan of since 1970. Ireland and Portugal show the low- Action for Nutrition at the International Con- est values (32.18% and 32.23% respectively), ference on Nutrition in 1992 as a strategic while Austria and Denmark the highest ones framework for national food and nutrition poli- (42.54% and 42.78% respectively) (Figure cies. VII.2). In Italy, the energy intake from fat in Poor or unbalanced diets are risk factors for 1996 was 37.24% of the total energy intake; several chronic diseases. A diet characterised by this proportion is slightly lower than the EU a high proportion of high-fat dairy foods, fatty average (38.98%). meats, salt and energy-dense foods containing Figure VII.3 shows protein intake as a percent- sugars and by a low proportion of vegetables, age of the total energy intake within the main fruit, cereals and legumes poses an increased sub-regional groups of countries in the WHO risk of non-communicable diseases, such as car- European Region. The value for Italy has diovascular diseases and cancer. The average increased very little since 1970 and was slightly fat consumption as a proportion of total ener- above the EU average value in 1996 (WHO gy intake increased slightly in the WHO Euro- 1999c).

Figure VII.1: Energy intake from fat in subregional groups of countries in the WHO European Region. Time trend.

Source: WHO, 1998b. Health determinants: Nutrition, lifestyle, physical environment and human settlements - 111

Figure VII.2: Energy intake from fat per person in EU countries. Time trend.

Source: WHO, 1998b.

Figure VII.3: Energy available from proteins per person in the WHO European Region. Time trend.

Source: WHO 1999c 112 - Health determinants: Nutrition, lifestyle, physical environment and human settlements

TARGET 4 - HEALTH21

By the year 2020, young people in the Region should be healthier and better able to fulfil their roles in the society.

In particular: 4.1. children and adolescents should have better life skills and the capacity to make healthy choices1. 4.2. mortality and disability from violence and accidents involving young people should be reduced by at least 50%2. 4.3. the proportion of young people engaging in harmful forms of behaviour such as drug, tobacco and alcohol consumption should be substantially reduced. 4.4. the incidence of teenage pregnancies should be reduced by at least one third3.

A survey conducted by the National Institute of for both men and women under 50 years, the Nutrition between 1990 and 1994 reports the effect of excess weight on mortality persists percentage of energy intake from diet for the throughout the entire lifespan. Obesity is now Italian population (Table VII.1). seen as an independent risk factor for coronary disease and has a strong correlation with diabetes, gall bladder disease, hypertension, can- Table VII.1: Percentage of energy intake cer and several non-fatal health problems. An from different dietary con- estimated 2-7% of health care costs are attrib- stituents in Italy. uted to obesity (WHO, 1998b). Although data on the prevalence of obesity and PERCENTAGE excess weight are limited in Europe, some From total fat 35.7 national studies suggest that about 10-20% of From animal fat 13.0 men and 10-15% of women are obese. Italy From total carbohydrates 48.4 shows one of the lowest percentages of over- From sugar 12.6 weight people among the European countries, From protein 15.9 both for females and males (Figures VII.4a and VII.4b). Source: Ministry of Health of Italy, 1998. The countries in the Eastern part of the Region have a higher prevalence of obesity than those in western Europe. The prevalence of obesity 1.2 Obesity has increased by 10-40% in most European countries over the past decade. In addition, Obesity is recognized as one of the main pre- obesity in many industrialized countries is asso- ventable causes of illness. For example, the ciated with various psychological problems. In mortality rate rises with the increase of relative 1997, WHO issued a series of recommenda- body weight. Although this increase is steeper tions for adopting preventive measures.

1 See Chapter VI. 2 See Chapter VI. 3 See Chapter III. Health determinants: Nutrition, lifestyle, physical environment and human settlements - 113

Figure VII.4a: Overweight population with body mass index ≥27 in selected countries in the WHO European Region. Females. Last available year.

Source: WHO, 1998b.

Figure VII.4b: Overweight population with body mass index ≥27 in selected countries in the WHO European Region. Males. Last available year.

Source: WHO, 1998b. 114 - Health determinants: Nutrition, lifestyle, physical environment and human settlements

TARGET 11 - HEALTH21

By the year 2015, people across society should have adopted healthier patterns of living.

In particular: 11.1 healthier behaviour in such fields as nutrition, physical activity and sexuality should be substantially increased. 11.2 there should be a substantial increase in the availability, affordability and accessibility of safe and healthy food.

Figure VII.5: Infants breastfed at 3 months of age in selected European countries.

Source: WHO, 1999c. Health determinants: Nutrition, lifestyle, physical environment and human settlements - 115

1.3 Breast-feeding An investigation conducted by the “Burlo Garofolo” Institute in Trieste reviewed 16 Good nutritional habits start early in life. Breast- studies on breastfeeding in Italy that were feeding improves infant growth and prevents published after 1990. The review reports a children from diseases and obesity later in life. It prevalence of breastfeeding in the neonatal also facilitates the intake of vitamins and iron as period ranging from 66% to 91%, decreasing well as proper psychological growth. Prevalence to 17-52% at four months and 28-36% at six of breastfeeding in the first six months of life months. However, the authors conclude that varies widely within the Region (Figures VII.5 and the real figures may be lower, as the review is VII.6). The WHO European Office reports breast based on preliminary data from one small feeding rates in 57 sites ranging from 29% to Region in Italy. On examining a 9-month fol- 97% in the years between 1968 and 1986. This low-up where definitions and methods were large variation may be attributable either to dif- standardized, exclusive breastfeeding aver- ferences in the definition of breastfeeding aged 35% upon hospital discharge and 23% habits, or to reporting mechanisms (whether to at about four months of age. (Tamburlini et a public hospital or to a private paediatrician). al., 1999, unpublished).

Figure VII.6: Infants breastfed at 6 months of age in selected European countries.

Source: WHO, 1999c. 116 - Health determinants: Nutrition, lifestyle, physical environment and human settlements

2. LIFESTYLE 2.2 Tobacco

“Lifestyle” is a very broad concept encompass- 2.2.1 Impact on health ing a number of human activities. Tobacco smoking was responsible for an esti- 2.1 Physical activity mated 1.2 million deaths in the European Region in 1995 (or about 13% of all deaths) A regular level of physical activity has great and for about one third of all cancer cases. In potential in improving health and well being. the CCEE and NIS, 20% of all men aged 35 will Health gains from physical activity include die from a tobacco-related illness by the age of enhanced mood and self-esteem, improved 69: this is twice the rate for middle-aged men physical appearance and a substantial reduc- in the Western Europe. Tobacco products are tion of several cancers, premature mortality, responsible for 25% of the social gradient of obesity, high blood pressure, cardiovascular dis- mortality associated with coronary disease in eases, non-insulin-dependent diabetes and Western Europe. Smoking-related deaths in osteoporosis. Doing more physical activity middle-aged people are responsible for 19 to would probably reduce the risk of disease also 23 years of life lost per person in the WHO by controlling other risk factors like smoking or European Region. dietary fat intake. Only a few countries in the Although the death rate from smoking-related European Region monitor the level of physical diseases among men is decreasing in Western activity (Figures VII.7a and VII.7b). Europe, the rates for women continue to The health behaviour in the School-age Chil- increase. In the CCEE and NIS, the number of dren study, which covers 19 countries of the deaths attributable to smoking is increasing in WHO European Region, found in 1993-1994 both sexes. If current trends are confirmed in that between 60% and 90% of 11-15 year-old the future, by the year 2020, tobacco will kill boys and between 40% and 80% of 11-15 more people world-wide than any other single year-old girls reported that they exercised vigor- cause. ously two or more times per week. In Italy, a Children’s health is also damaged by smoking. survey conducted by ISTAT among Italian fami- Mothers smoking during pregnancy can nega- lies reported that the highest percentage of tively affect the weight of new born babies, as people who said they practised physical activity well as their childhood and perhaps adult on a regular basis was among 11-14 years old health. Recent data demonstrate that babies of (51.4% of the population), with the lowest smokers are more likely to die from sudden value among those aged 65 and above (2.9%) infant death syndrome than babies of non- (Figure VII.8) (ISTAT, 1998b). smokers (WHO, 1999b).

TARGET 12 - HEALTH21

By the year 2015, the adverse health effects from the consumption of addictive substances such as tobacco, alcohol and psychoactive drugs should have been significantly reduced in all Member States.

In particular: 1.1 in all countries, the proportion of nonsmokers should be at least 80% in over 15–year-olds and close to 100% in under 15-year-olds; 1.2 in all countries, per capita alcohol consumption should not increase or exceed 6 litres per annum, and should be close to zero in under 15year-olds. 1.3 in all countries, the prevalence of illicit psychoactive drug use should be reduced by at least 25% and mortality by at least 50%. Health determinants: Nutrition, lifestyle, physical environment and human settlements - 117

Figure VII.7a: Females physically active in their leisure time, by age group, in selected countries in the WHO European Region.

Source: WHO, 1998b.

Figure VII.7b: Males physically active in their leisure time, by age group, in selected countries in the WHO European Region.

Source: WHO, 1998b. 118 - Health determinants: Nutrition, lifestyle, physical environment and human settlements

Figure VII.8: Population practising physical activity by age group in Italy – 1997.

Source: WHO, 1998b.

2.2.2 Smoking habits Cigarette use is increasing in 15 of the 36 countries for which data are available (mainly in the In the first half of the 1990s, around 30% of eastern part of the Region), it is decreasing in the adults in Europe were daily smokers and, so another 14 (mainly Western Europe) and far, no country has met the target for the year remains stable in 7. 2000 of 80% non-smokers. Smoking among women is increasing in 15 Although the percentage of smokers is general- countries and, in some countries is now equal ly higher in the CCEE and NIS than in Western to or higher than that among men (WHO, Europe, a high percentage of the population 1998b). continues to smoke in some countries in West- In Italy, data on smoking prevalence are available ern Europe (Figure VII.9). from the periodic national statistics survey per- Health determinants: Nutrition, lifestyle, physical environment and human settlements - 119

Figure VII.9: Prevalence of smoking by gender in the WHO European Region - early to mid 1990s.

Source: WHO, 1998b.

formed among a sample of Italian people above 13 cern to policy makers. However, the lack of years of age (see Chapter XVI on methodology). standardization of age-groups and definitions About 12 800 000 people smoked in Italy in of smoking in many independent surveys car- 1996, that is 26.1% of the population aged 14 ried out on smoking among young people in or more. There are marked gender and age dif- the Region demands caution in any generaliza- ferences (Figures VII.10a and VII.10b) (ISTAT, tion about rank order or time trends (WHO, 1998c). 1997a). Many studies show that those who smoke as Data for some countries of the European adults generally started doing so by the age of Region are available from the WHO-sponsored 18; therefore, knowledge of trends in the Health Behaviour in School-age Children uptake of smoking in teenagers is of major con- (WHO, 1996) (Table VII.2). 120 - Health determinants: Nutrition, lifestyle, physical environment and human settlements

Figure VII.10a: Smoking habits among Italian females by age group – 1996.

Source: WHO, 1998c.

Figure VII.10b: Smoking habits among Italian males by age group – 1996.

Source: WHO, 1998c. Health determinants: Nutrition, lifestyle, physical environment and human settlements - 121

Table VII.2: Percentage of 15-years-old boys and girls smoking at least once a week in selected European countries – 1989/1990 and 1993/1994.

COUNTRIES BOYS GIRLS 1989/1990 1993/1994 1989/1990 1993/1994 Austria 23 29.0 20 31.2 Belgium (French) 15 32.2 17 18.0 Belgium (Flemish) 22.6 20.7 Czech Republic 16.0 11.9 Denmark 14.4 23.6 Estonia 21.6 5.7 Finland 33 29.8 32 26.2 France (Nancy and Toulouse) 23.0 25.0 Germany (Nordrhein Westfalen) 20.9 28.8 Greenland 48.5 46.1 Hungary 31 25.0 20 19.1 Israel 9.3 8.8 Latvia 33.1 14.1 Lithuania 14.8 4.0 Northern Ireland 23.4 24.9 Norway 21 20.2 23 21.0 Poland 20 22.5 10 12.8 Russian Federation (St. Petersburg) 19.4 9.7 Slovakia 18.7 4.8 Spain 18 20.3 27 26.9 Sweden 15 15.1 20 19.3 Scotland 16 20.5 18 25.9 Wales 14 18.2 22 26.5

Source: WHO, 1996.

According to the Italian national survey, the questionnaire for parents in the National Sur- estimated prevalence of smokers among 14 vey) may explain the different proportion of year-olds is 1.8% and 1.6% respectively among smokers reported among young adolescents males and females. The frequency of smokers in the two studies (SIDRIA, 1997b; SIDRIA, greatly increases with age, to 30.9% among 1998). males and 14.7% among females 18-19 years The prevalence of smoking is higher among old (ISTAT 1998c). males (34.9% versus 17.9% among females Data are also available from the recent SIDRIA in 1996), although women show a moderate study (SIDRIA, 1997b). The estimated preva- but progressive increase in smoking habits lence of younger smokers (self-reported by stu- (Table VII.3): this is shown by the male/female dents aged 13-14 years) was 8.8%, with some ratio which decreased from 2.6 in 1983 to differences among Italian areas, ranging from 1.95 in 1996. For both sexes, the highest pro- 6.4% in Empoli (Toscana) to 12.7% in Viterbo portion of smokers is observed in the age (Lazio) (Figure VII.11). group 35-44 (42.9% in males and 29.7% in Data collection methods (a questionnaire for females). children in the SIDRIA as compared to a 122 - Health determinants: Nutrition, lifestyle, physical environment and human settlements

Figure VII.11: Smoking habits among adolescents (13-14 years) in different Italian areas participating in the SIDRIA study.

Source: SIDRIA, 1997b.

Table VII.3: Prevalence of smokers in the Italian population. 1993-1996. YEAR SMOKERS EX-SMOKERS

MALES FEMALES TOTAL MALES FEMALES TOTAL

1993 35.1 16.4 25.4 26.5 12.4 19.2 1994 34.1 16.7 25.1 26.6 13.0 19.6 1995 33.9 17.2 25.3 27.4 13.1 20.0 1996 34.9 17.9 26.1 26.9 12.2 19.3

Source: ISTAT, 1998c. Health determinants: Nutrition, lifestyle, physical environment and human settlements - 123

Males usually smoke more cigarettes than general practitioners than among the general females; overall, 10.4% of people in 1996 population (Figure VII.13). smoked more than 20 cigarettes per day The percentage of smokers among doctors in (13.6% among males and 4.7% among Italy is very high, second only to the figures for females). Spain. This rises concern about the role of As regards ex-smokers, data for 1996 show a “health educators” which health staff and doc- reverse of the increasing trend observed in the tors, in particular, are called on to play both for period 1993-1995, particularly among females their patients and the general population. (TableVII.3). There are some differences in the distribution of 2.3 Alcohol smokers among the main geographical areas in Italy; for both sexes, a higher prevalence can be 2.3.1 Impact on health observed in the Centre (27.9% overall). How- ever, the highest prevalence of male smokers Many epidemiological studies show that drink- was reported in the South and in the Islands (37 ing small quantities of alcohol reduces the risk and 38.6% respectively), while female smokers of coronary disease and ischaemic strokes; most were more frequent in the Centre (21.4%) (Fig- of the risk reduction occurs at the level of 10 ures VII.12a and VII.12b). grams of absolute alcohol (which correspond When looking at the figures on a regional level, approximately to a glass of beer of 250ml, a Lazio and Campania show the highest preva- glass of wine of 125ml, and a measure of spir- lence of smokers (30.4% and 28.2% respec- its of 25ml) every day. tively). As for ex-smokers, Northern and Central However, high alcohol consumption, especially regions show a higher frequency of ex-smokers when combined with the practice of drinking to as compared to the South and the Islands: the intoxication, leads to a tremendous increase in regions of Emilia Romagna and Marche show mortality. Alcohol is a dependence-producing the highest percentage (23.2% in both regions) drug, and this dependence is associated with (ISTAT, 1998c). an increased risk of illness and premature Smoking habits are associated with educational death: drunkenness is also associated with a level: the higher the education level, the higher high risk of injury and death, both to the per- the smoking prevalence among females, while son who becomes intoxicated and to others. the opposite is true for males. Among universi- Death rates for chronic liver disease and cirrho- ty graduates, gender-related differences have sis of the liver, of which a significant part is almost disappeared (26% among males and associated with alcohol consumption, vary 22% among females) (Ministry of Health of widely throughout the Region. The highest and Italy, 1999c). most rapidly increasing rates are found in coun- In some professional categories, such as those tries in the Eastern part of the Region (Figure working in the health sector, there is a higher VII.14) (WHO, 1999c). frequency of smoking compared to the overall The average mortality in the EU, although population. This is particularly relevant as slightly declining, is still about twice as high as health professionals are an important group for the average of the Nordic countries. health education and population behavioural According to Italian statistics for road accidents, change promotion. A survey carried out in more than 2 437 road accidents were caused 1988 on general practitioners working in what by drunken drivers in 1997 (that is 1.7% of the was then the EU Member States (Belgian Asso- total traffic accidents), with 79 deaths and ciation for Smoking Prevention, 1989) shows more than 3 710 injured persons (2% and that in a third of the countries studied, includ- 1.8% of total deaths and injured respectively) ing Italy, smoking is more wide-spread among (ISTAT, 1997e). 124 - Health determinants: Nutrition, lifestyle, physical environment and human settlements

Figure VII.12a: Female smokers in different areas of Italy - 1993-1996.

Source: ISTAT, 1998c.

Figure VII.12b: Male smokers in different areas of Italy - 1993-1996.

Source: ISTAT, 1998c. Health determinants: Nutrition, lifestyle, physical environment and human settlements - 125

Figure VII.13: Smoking habits among general practitioners and general population in 12 EU countries – 1989.

Source: Belgian Association for Smoking Prevention, 1989.

Figure VII.14: Standardized death rate for chronic liver disease and liver cirrhosis in subregional groups of countries in the WHO European Region. Time trend.

Source: WHO, 1999c. 126 - Health determinants: Nutrition, lifestyle, physical environment and human settlements

Figure VII.15: Registered and estimated unregistered annual consumption of pure alcohol equivalent in selected countries in the WHO European Region - early to mid 1990s.

Source: WHO, 1998b. Health determinants: Nutrition, lifestyle, physical environment and human settlements - 127

2.3.2 Alcohol consumption 2-3 times higher than those shown in routine statistics. In ninety per cent of the European countries The sharp increase in the incidence of alcoholic people consume in excess of 2 litres of pure psychosis in Eastern European countries alcohol per capita a year. The amount of 2 litres between 1992 and 1995 provides additional corresponds to the lowest mortality risk for the evidence for increasingly high alcohol con- population (Figure VII.15). sumption. Alcohol consumption in 21 countries, mainly In most Western European countries, especially in the Eastern part of the Region, either those with high alcohol consumption, trends increased over the entire period 1980-1993 or are declining or stable (Figure VII.16). (WHO, has been increasing in more recent years, but 1998b). the official data for alcohol sales in the CCEE Only Italy, France and Spain have achieved their and NIS do not indicate the real situation target for the year 2000 to reduce alcohol con- because much consumption has been largely sumption by 25% between 1980 and 1995. unrecorded. Studies carried out in some coun- Alcohol consumption has been decreasing in tries suggest that actual consumption may be Italy since 1981 (Table VII.4) (Scafato, 1998).

Figure VII.16: Registered annual consumption of pure alcohol equivalent in selected countries in Western Europe. Time trend.

Source: WHO, 1997b. 128 - Health determinants: Nutrition, lifestyle, physical environment and human settlements

Table VII.4: Trends in alcohol per capita consumption (litres/year) in Italy.*

BEVERAGES 1981 1991 1995 1996 1997 CHANGES (%) CHANGES (%) ESTIMATE 1981-1991 1991-1996 Wine 86.2 62.1 55.7 54.3 53.5 –27.9 –37.0 Beer 17.9 24.9 25.4 24.0 25.0 +39.1 +34.1 Spirits 1.4 1.0 0.8 0.7 0.7 –28.6 –50.0

Alcohol 11.7 9.1 8.4 8.1 8.0 –22.2 –30.8 Alcohol (age >15y) 14.9 10.8 – – – –27.5 –

* Based on PVGD estimation (Produktschamp Voor Gedistilleerde Dranken); Availability method: Consumption = National production + (import – export) – Other Use + Stocks. Source: Scafato, 1998.

These figures are also confirmed by a survey on 2.4 Psychoactive drugs the expenditure of Italian families for home consumption of food and beverages. However, Europe is estimated to have 1.5-2,0 million this survey does not take into account alcohol heavy users of psychoactive drugs. The preva- consumption outside the home. Various rea- lence of people who have ever taken drugs sons may explain the downward trend and of current users varies considerably from observed; population ageing, new socio-cultur- country to country. There is an increased use al models among young people, as well as of most drugs, including cannabis, opiates, reduced purchasing power due to unemploy- amphetamines and cocaine, throughout the ment and reduced income levels. The same sur- Region, especially in the Eastern part, vey indicates that 7.2% of people (about although the number of heavy opiate users 3 500 000 persons) reports drinking alcoholic has stabilized or declined in some Western beverages outside main meals more than once European countries. The consumption of a week; this behaviour is more frequent in the amphetamine-like substances (such as ecstasy) North-East of the country (10.7%) (ISTAT, is increasing rapidly in many Western Euro- 1997f). pean countries. Although information on alcohol consumption Providing an overview of illicit drug consump- among young people is more scarce, there is tion levels and trends in the WHO European evidence that alcohol consumption is increasing Region, is a task which must be approached among young people in the WHO European with caution, due to the differences in the Region - (Figure VII.17). nature and comprehensiveness of data collec- Alcohol consumption among children and ado- tion systems. It is particularly difficult to make lescents in the European Community was inves- accurate comparisons between countries (WHO tigated in 1990. Large differences in the preva- 1998b). The use of illicit drugs in the Nether- lence of weekly drinkers by country were lands among 12-18-year-olds (13.6%) appears found. Prevalence rates in Italy and Greece to be higher than in, for example, Greece, were more than twice the average on the one Malta or Portugal, where it is about 4-5% hand, while on the other hardly any children (7.4% in Lisbon). Among adults, regular use is were found to drink in Ireland (Van Reek, considerably lower than occasional use in all 1994). cases. Health determinants: Nutrition, lifestyle, physical environment and human settlements - 129

Figure VII.17: 15-year-olds boys and girls drinking alcohol at least once a week in selected WHO European countries - 1993-1994.

Source: WHO, 1996.

In a sample taken from the military service med- drug-users were under therapy in public and ical examination reports of the period 1993- private institutes: a progressive and marked 1994 concerning 35 000 Italians aged 18 years, increasing time-trend can be observed, particu- about 14% stated they currently used certain larly over the last five years. illicit drugs, and 5% stated they had used them Most drug users in therapy are young, mainly in the past. Most of the users reported con- aged 20-35 years, and more frequently males sumption of hashish or marijuana (15.1%), (84.8% in June 1996). Most drug-users in ther- while 2.5% reported the use of opiates. apy in public health structures are heroin- Among users, the percentage of daily users was dependent (about 90%); general or exclusive 10.8%, while 19.1% stated they used illicit dependence on other substances (hashish, drugs once a week and 56.3% more rarely cocaine etc.), is rarely a reason to request assis- (ISTAT, 1997f). tance from public health services. Data from the Italian Ministry of Internal Affairs The total number of deaths due to drug use in (Osservatorio permanente sul fenomeno droga) 1997 was 1 153. About 40% of AIDS cases in show that as of June 1996, more than 107 000 Europe are among drug users (Table VII.5). 130 - Health determinants: Nutrition, lifestyle, physical environment and human settlements

Table VII.5: Estimates of drug addicts in Italy.

1990 1991 1992 1993 1994 1995 1996 1997

Number of drug addicts* 67 500 92 853 103 805 104 742 113 742 123 828 129 828 131 717 Deaths through overdose** 1 161 1 383 1 217 888 867 1 195 1 566 1 153 Deaths through overdose+ 1 094 1 180 1 093 760 809 Mortality rate for overdose (x 1 000)° 8.9 7.4 6.2 4.3 4.9 5.9 Estimates of total drug addicts° 130 449 186 891 196 290 206 511 176 938 202 542

* Receiving treatment at INHS’ facilities, Ministry of Health, 1997. ** From the “Anti-drug Central Service” of the Ministry of Internal Affairs, 1997. + From ISTAT, 1997c. ° Data derived from a study carried out in Rome 1980-1995. Davoli et al., personal communication, 1999.

2.5 Safe sex (Borgia et al., 1999, personal communication). Part of the total disease burden within the WHO Region is estimated to result from unsafe sex. The current syphilis epidemics in the NIS 3. PHYSICAL ENVIRONMENT AND HUMAN are one example of this. The rapid increase in SETTLEMENTS HIV transmission related to drug use and the new epidemics of Sexually Transmitted Diseases In the early 1990s, the WHO European Centre for (STDs) in the Eastern part of the Region also Environmental and Health carried out a compre- increase the danger of sexually transmitted HIV hensive analysis of the state of the environment infection. Changes in sexual behaviour and atti- and health in the European Region. The resulting tudes as well as increased travel, poverty, report, Concern for Europe’s Tomorrow (CET), unemployment and prostitution all contribute was presented at the Second European Confer- to the rapid increase in STDs (see Chapter V, ence on Environment and Health in Helsinki in sections 3.7 and 3.8). June 1994 and was the basis for the develop- A study carried out in 1990 provides informa- ment and adoption by the Ministers of Health tion on safer sex practices and condom use. and Environment of the European Environment Over half of the individuals surveyed, which and Health Action Plan (WHO-ECEH, 1995). An accounted for 57%, declared they did not use update of the data and information included in any kind of contraceptive in the six months the CET was carried out recently as part of the before the STD diagnoses, while 25.3% preparatory process of the III Interministerial Con- reported that they sometimes used condoms. ference on Health and Environment held in June In Italy several studies were conducted to 1999 in London (WHO, 1999d). investigate sexual behaviour and condom use. A similar comprehensive analysis of the Envi- A review from Aloisi et al. analyses the results ronment and Health situation was carried out in of various Italian studies conducted from Italy by the WHO European Centre for Environ- 1990 to 1994 on young people’s knowledge ment and Health, Rome Division, and published of and behaviour related to HIV infection in an extensive report named “Ambiente e (Aloisi, 1995). The percentage of regular use Salute in Italia” (WHO-ECEH, 1997). This publi- of condoms ranges from 20% to 67% among cation should be consulted for more detailed young men. A recent study shows that 65.8% data and analyses of the environmental health of young adults (16-23 years) use condoms situation in Italy. Health determinants: Nutrition, lifestyle, physical environment and human settlements - 131

TARGET 10 – HEALTH21

By the year 2015, people in the Region should live in a safer physical environment, with exposure to contaminants hazardous to health at levels not exceeding internationally agreed standards.

In particular: 10.1. population exposure to physical, microbial and chemical contaminants in water, air, waste and soil that are hazardous to health, should be substantially reduced, according to the timetable and reduction rates stated in national environment and health action plans. 10.2. people should have universal access to sufficient quantities of drinking-water of a satisfactory quality.

3.1 Air pollution (CO2) which are formed by reactions in the atmosphere. Combustion is also the source of a Good quality air is an important determinant of large group of polycyclic aromatic hydrocar- health. Improvements in epidemiological bons (PAHs). Gasoline combustion or evapora- research during the 1990s and recent more in- tion is a major source of benzene and a range depth studies revealed that people’s health may of other volatile organic compounds of known be affected by exposure to much lower levels of toxicity. Heavy metals, such as lead (Pb), may be certain common air pollutants than was present in the atmosphere due to emission believed even a few years ago. While the “no- from industry and from the exhausts of engines risk” situation is unlikely to be achieved, a min- using leaded fuels. imization of the risk should be the objective of In most cases, the individual pollutants should air quality management. Another important be considered as indicators of the pollutant development in the 1990s was the recognition mixture as well as of the intensity of emissions of the health significance of breathable particu- from certain classes of pollution sources. In this late matter (PM10 or PM2.5, i.e. particulate mat- respect, the group of “classical” air pollutants ter whose aerodynamic diameter is less than 10 (SO2, SPM, NO2 and O3) is the group studied. and 2.5 µm, respectively). Exposure assessment is based on information on the concentration of the pollutants in ambi- 3.1.1 Environmental air quality ent air measured by the existing monitoring networks and collected by relevant local, People are exposed to a mixture of pollutants national or international authorities. which are emitted into the atmosphere by sev- To allow for a more direct comparison of data, eral sources, and mix with the air with a variety the population of cities with air pollution data of temporal and spatial patterns. The best stud- was divided into categories according to the ied and most common health pollutants are concentration of pollutants in the most recent those emitted during fossil fuel combustion, years between 1994 and 1997 for which data such as suspended particulate matter (SPM), were available (Table VII.6). Since no reference sulphur dioxide (SO2), carbon monoxide (CO) or values is proposed by WHO for total suspended nitrogen oxides (NOx), and secondary pollu- particulates (TSP) or black smoke (BS) (WHO- tants, such as ozone (O3) or carbon dioxide ECEH, 1999), the categorization roughly 132 - Health determinants: Nutrition, lifestyle, physical environment and human settlements

assumes that the mass estimate of BS is equiv- and industrial processes (15-30%). However,

alent to PM10, while 50% of TSP accounts for the contribution of traffic to ground level urban

PM10. This takes into consideration both the dis- concentrations and exposures is considerably tribution of the pollution in the European cities larger than this sector’s contribution to emis-

and the health relevance of the pollution levels. sion. PM10 or PM2.5 monitoring is still very limit- Moving from the “low” to the “medium” and ed in Europe and availability of the data for a “high” category, the likelihood of negative European analysis is even poorer. The predomi- health effects on the population increases. nant technique used to assess suspended par- However, the main aim of this categorization is ticulates remains gravimetric measurements of to illustrate the variability of pollution in the TSP or BS. European Region, rather than attributing any In the mid-1990s, less than 16% of the popu- “severity score” to the categories employed. lation in cities for which data are available fall into the “low” category of one of the measures of particulate matter, and almost 44% live in Table VII.6: Categorisation of annual aver- cities with “high” levels of particulate pollution age pollution level. (Figure VII.18) (WHO, 1999d). The highest levels of particulate pollution, with SPM* SO2 NO2 an annual TSP average exceeding 150 µg/m3 in Low <20 <20 <40 1995-96, were reported from several cities in Medium 20-30 20-50 40-60 Belarus and Bulgaria. The highest BS levels were High >30 >50 >60 reported in Athens (99 µg/m3). Trends in particulate pollution concentration in the 1990s *SPM=PM10 or BS or 0.5 TSP. show a decrease rather than an increase in Source: WHO, 1999d. most cities. However, in cities classified as highly polluted, an increasing trend was more common (affecting 24% of population in these Data used to describe the situation in Italy cities) than in cities with low or medium con- come from an on-going study carried out by centrations of particulates (12%) (WHO, the WHO European Centre for Environment 1999d). and Health in Rome. The concentration values Data from the ITARIA network are difficult to are provided by the existing networks in the interpret because of the different methodolo- eight largest Italian cities within the framework gies employed in the monitoring networks. In

of a collaborative group named ITARIA (WHO- addition, data on PM10 have only been collect- ECEH/ITARIA, 1999b). ed very recently. TSP annual means in the eight cities in 1997 ranged from 30.7 µg/m3 in Gen- 3 Particulate matter ova to 70.1 µg/m in Napoli. In 1997, PM10 annual mean concentrations directly measured Airborne particulate matter represents a com- in urban traffic stations ranged from 40 to 49 3 plex mixture of organic and inorganic sub- µg/m in the city of Firenze and from 47 µg/m3 stances, which are most easily characterised by to 51 µg/m3 in Palermo. In Roma the mean aerodynamic diameter. The particles denoted as annual concentrations in 1998 ranged from 43 3 3 PM10 (less then 10 µm in aerodynamic diameter) µg/m to 55 µg/m in three urban monitoring can penetrate beyond the larynx and are com- stations and 27 µg/m3 in a station located in a parable with the thoracic or respirable particu- park. The government decree of 25/11/94 3 late matter. The main sources of total anthro- defines a “quality target” for PM10 of 40 µg/m

pogenic emissions of primary PM10 are traffic as of 1 January 1999 (WHO-ECEH/ITARIA, (10-25%), stationary combustion (40-55%) 1999). Health determinants: Nutrition, lifestyle, physical environment and human settlements - 133

Figure VII.18: Population distribution by air pollution level in the WHO European Region in the mid-1990s.

Source: WHO, 1999d.

Sulphur dioxide of people (less than 2%). The highest concentrations (over 170 µg/m3), which were reported

The main source of sulphur dioxide (SO2) in ambi- from Bulgaria (Asenovgrad and Plovdiv), have ent air is the combustion of sulphur-containing markedly increased over the 1990s. In most other fossil fuels. Short-term (minutes to hours) expo- cities, which were inhabited by 73% of all people sure to high SO2 levels may occur downwind of included in this analysis, the SO2 levels are medi- point sources, while the area sources (such as um or low and decline with the annual rate domestic heating and urban traffic) mainly con- exceeding 5%. tribute to exposures lasting several days. This is In Italy, there is a decreasing trend of concen- especially the case in cold winter months, with trations over time for sulphur dioxide (Figure stable weather restricted dispersion. Thus SO2 is VII.19). All the cities show mean annual con- mainly a problem of urban areas and contributes centrations below the WHO guidelines (50 to what is termed “winter smog”. As illustrated µg/m3) and fall into the low concentration cat- in Figure VII.18, almost 60% of the population egory. However, Genova still shows a medium 3 for which SO2 data are available for this analysis concentration (28 µg/m ), which is higher than live in areas with low SO2 levels. High annual that observed in all other major cities (WHO- average SO2 levels only affect a small proportion ECEH/ITARIA, 1999). 134 - Health determinants: Nutrition, lifestyle, physical environment and human settlements

Figure VII.19: Mean annual sulphur dioxide concentration (24-hour average) in the eight largest Italian cities. ITARIA Group - 1994-1998.

Source: WHO-ECEH/ITARIA, 1999.

Nitrogen dioxide tial variability of NO2 concentrations is quite distinct, with city centre levels typically twice as

Nitrogen dioxide (NO2) is an important atmos- high as those in the suburbs, and with urban pheric trace gas not only because of its possible levels four to five times higher than in rural

direct health effects, but also because of a num- areas. NO2 concentrations near a busy road may ber of associated ecological effects. It also plays be 40% higher than at a distance of 20-30 m

a critical role in determining ozone (O3) concen- from the road and 60-70% higher than further

trations in the troposphere because NO2 photol- away. Only 23% of the population studied live ysis is the key initiator of the photochemical for- in cities where the annual air quality guideline mation of ozone. The major source of human level is not exceeded. In Italy, most of the mon-

exposure to NO2 in ambient air is the combus- itoring stations in all eight main cities have an tion of fossil fuels in stationary sources (heating, annual concentration above the recommended

power generation) and in motor vehicles (inter- WHO guidelines for NO2 (1-hour average) of 40 nal combustion engines). In most ambient situ- µg/m3. The concentrations measured in urban ations, nitrogen monoxide (NO) is emitted and traffic stations are quite high, ranging from 48 3 3 3 transformed into NO2 in the atmosphere. Emis- µg/m to 158 µg/m (80 µg/m on average). Fur- sions from motor vehicles, which account for thermore, the proposed EU air quality standard 50% of the total emissions and for almost 75% of 200 µg/m3 (as 99.8 percentile) was frequent- in urban areas, are the most important determi- ly overcome in most of the cities, particularly in nants of human exposure outdoors due to their Milano and Napoli (Figure VII.20) (WHO- impact on “breathing zone” air quality. The spa- ECEH/ITARIA, 1999). Health determinants: Nutrition, lifestyle, physical environment and human settlements - 135

Figure VII.20: Nitrogen dioxide (1 hour average) in the eight largest Italian cities - ITARIA Group – 1998.

Source: WHO-ECEH/ITARIA, 1999.

Ozone for more than 25 days. The highest concentrations (>240 µg/m3) were recorded in Italy and Since ozone is formed as a secondary pollutant, Greece. Frequent peaks in ozone levels were high concentrations may be found far away also reported from Slovenia (44 and 92 days 3 from the sources of primary pollutants causing with 8-hour O3 > 110 µg/m in 1995 and 1996, ozone formation (NO2 and Volatile organic respectively) (WHO, 1999). compounds) in photochemical reactions. Gen- The distribution of 8-hour means (in the time erally, ozone concentrations in city centres are internal between noon and 8 p.m.) in the 8 lower than those in suburbs, mainly as a result cities monitored by the ITARIA network in 1998 of the scavenging of ozone by NO originating is summarised in Figure VII.21. The data indi- from traffic. According to the EU directive, the cate that in several days in 1998 the Italian occurrence of ozone in concentrations exceed- guideline value (8 hour mean of 110 µg/m3 - ing 110 µg/m3 (8-hour average) must be report- DM 16/5/96) for health protection was widely ed to the European Commission. In 1995, 90% exceeded in all cities, particularly in Roma, of EU population (both, urban and rural) expe- Genova and Napoli. The ozone situation has rienced levels well above the threshold for at been getting worse over the last few years. For least one day during the summer of 1995. Over instance, a “warning state” corresponding to 80% experienced exposure above the threshold ozone levels over 180 µg/m3 was present in 136 - Health determinants: Nutrition, lifestyle, physical environment and human settlements

Figure VII.21: Ozone concentrations (8 hour mean in the time interval 12 a.m. - 8 p.m.) measured in selected urban background stations in the eight largest Italian cities - ITARIA Group – 1998.

Source: WHO-ECEH/ITARIA, 1999.

Roma for 21 consecutive days from 29 July to zene derives from transport-related activities; 19 August 1998. In two green areas close to however, in the indoor environment, the ben- densely populated parts of town and which are zene release associated with tobacco smoking visited regularly by children and elderly people makes a significant contribution to exposure (Preneste and Ada) the “health protection levels. Benzene is a human carcinogen (Group I level” was exceeded 110 and 147 times, of IARC classification). It has been estimated respectively, in the time interval between noon that in Italy between 16 and 275 new cases of and 8 pm. In a suburban area south west of leukemia can be attributed annually to benzene Rome, this level was exceeded for 217 days in exposure (WHO-ECEH, 1997). the same time interval (WHO-ECEH/ITARIA, A Ministerial Decree (25/11/94) has set new 1999). limits for acceptable concentrations of benzene in the outdoor air as of 1 January 1999. How- Benzene ever, in July 1998, only 11 out of 23 major Ital- ian cities in which these limits apply had set up Benzene is a volatile organic compound whose proper monitoring networks (Legambiente, concentration in the environment derives main- Treno Verde, 1999). Moreover, a national survey ly from human activities. About 80% of ben- carried out by an environmental NGO detected Health determinants: Nutrition, lifestyle, physical environment and human settlements - 137

high concentrations of benzene in several Ital- 3.1.2 Indoor air ian cities (Legambiente, Treno Verde, 1999). Data from the existing monitoring networks In modern societies, human beings spend most confirm that, in most cases, the limit of 10 of their time (up to 90% in some countries) in µg/m3 is regularly exceeded. In Roma, for indoor environments: at home, at the work- instance, annual means of benzene concentra- place or in means of transport. The quality of tions ranged from 14.3 to 22.5 mg/m3 in three indoor air has become a matter of growing stations in 1998 and between 11.8 and 18.6 in concern over the last twenty years and is an the first 4 months of 1999. This may indicate a important public health issue. This concern was tendency to improvement over the last few initially triggered by reports from occupants of years as a consequence of both the decrease in various indoor environments who complained benzene concentration in petrol and the higher about a variety of unspecific symptoms, such as proportion of cars circulating with catalytic irritation or dryness of mucous membranes, exhausts. burning eyes, headache or fatigue. Because in some cases these symptoms could be related to Conclusion elevated concentrations of specific pollutants in indoor air, such as formaldehyde, increasing To summarize, the ambient air pollution situa- attention was devoted to assessing climate con- tion in Italy has improved over recent years with ditions and chemical compounds in the air in respect to traditional air pollutants such as SO2. closed environments. The more obvious effect This follows the trend observed in most western of extremely bad indoor air quality is acute poi- European countries in the same time period. soning by carbon monoxide (CO) due to incor- However, marked and indeed alarming levels of rectly, poorly ventilated or malfunctioning com- traffic related air pollutants have been bustion appliances; in actual facts carbon observed. These pollutants have been associat- monoxide pollution indoors is responsible for ed with a variety of health effects. In order to hundreds of deaths and hospital admissions in address these important issues, two different Europe every year. but complementary approaches are being Acute reactions to specific pollutants are only applied mainly by countries in Western Europe one of the reasons for concern about indoor and especially the Nordic countries in the WHO air pollution. Several chronic diseases have European Region. These aim to: been linked to various aspects of indoor air • reduce air pollution from mobile sources by quality. These include respiratory diseases (par- implementing legislative and fiscal instruments, ticularly among children), allergies (for example improving the technical specifications of vehicle related to housedust mites and animal fur) and engines and improving fuel quality; mucous membrane irritation (due to formalde- • reduce air pollution from fixed emission hyde, other irritant compounds and solvents). sources by identifying pollution sources, Large numbers of people have been, and are improving the technical processes and chang- still being affected. Asthma is reported to be ing the fuels used. on the increase in many countries (see Chapter In view of the particular structure of Italian IV). cities, these two intervention categories should The evidence accumulated until mid-1990s be accompanied by severe restrictions and reg- indicates that exposure to radon (Rn) decay ulations of traffic in urban areas, taking into products entails a greater risk of developing account all existing vehicles, including mopeds. lung cancer. Population exposure to radon The latter group makes a significant contribu- varies markedly across Europe, depending on tion to the concentrations of dangerous pollu- local geology and housing constructions, tants such as benzene. including insulation materials. Data from sever- 138 - Health determinants: Nutrition, lifestyle, physical environment and human settlements

al countries indicate an exposure range for tromagnetic fields emitted from these devices exposures higher than 200 Bq/m3, from 0.11% could have adverse health effects, such as can- of the population in the UK to 3.9% in Sweden cer, reduced fertility, memory loss, as well as (WHO-ECEH, 1995). In Italy, a national survey adverse changes in the behaviour and develop- conducted by the ISS in the early 1990s found ment of children. However, the actual level of that 5% of Italian people are exposed to more health risk is not known at present. than 200 Bq/m3 and 1% to more than 400 Concern about health risk includes static and Bq/m3 (Bochicchio et al., 1994). It has been esti- time varying electric and magnetic fields in the mated that 2 200-5 100 lung cancer cases per frequency range 0-300 GHz. This range year out of the total 32 000 cases (6.8%- includes static (O Hz), extremely low frequency 15.9%) can be attributed to radon exposure. (ELF, >0 - 300 Hz) and radio-frequency fields Many chemicals encountered in indoor air are (RF, 300 Hz - 300 GHz). For the Italian, preven- known or suspected to cause sensory irritation tion policies, see Chapter XIII. or stimulation. These, in turn, may give rise to a sense of discomfort and other symptoms com- 3.2.1 Radiofrequency (RF) Fields monly reported in so-called “sick” buildings. Large surveys carried out in offices and public Natural and human-made sources generate RF buildings in different countries revealed frequent fields of different frequency. Common sources complaints among 50% of the occupants. Per- of RF fields include: monitors and video display ceived deterioration of indoor air quality has also units (3 - 30 kHz), AM radio (30 kHz - 3 MHz), been reported in a large proportion of occupants industrial induction heaters (0.3 - 3 MHz), RF of houses, hospitals, kindergartens and other heat sealers, medical diathermy (3 - 30 MHz), community buildings. Complex mixtures of FM radio (30 - 300 MHz), mobile telephones, organic chemicals in indoor air also have the television signals, microwave ovens (0.3 - 3 potential to cause subtle effects on the central GHz), radar, satellite links, microwave communi- and peripheral nervous system, leading to cations (3 - 30 GHz) and the sun (3 -300 GHz). changes in behaviour and performance. Exposure to RF fields may cause heating or induce electrical currents in body tissues. Heat- 3.2 Electromagnetic fields ing is the primary interaction of RF fields at high frequencies, i.e. above 1 MHz. Below this fre- Recent years have seen an unprecedented quency, the induction of electrical currents in the increase in the number and diversity of sources body is the predominant action of RF exposure. of electric and magnetic fields (EMF) used for Population exposures to RF fields generated by individual, industrial and commercial purposes. telecommunication devices are difficult to Such sources include televisions, radios, com- assess. However, due to the extensive presence puters, mobile phones, microwave ovens, in the environment of radio and TV signals as radars and equipment used in industry, medi- well as telecommunication facilities, including cine and commerce. the widespread use of mobile phones, some All these technologies have made our life richer degree of exposure to this type of electromag- and easier and modern society is barely conceiv- netic field can be considered universal. able without them. At the same time, these A scientific review by WHO, published within technologies have brought with them concern the framework of the International EMF Project about the possible health risks associated with (WHO, 1999e), concluded that, from scientific their use. Such concerns have been raised about literature currently available, there is no con- the safety of mobile phones, electric power lines vincing evidence that exposure to RF shortens and police speed-control “radar guns”. Scientif- the life span of humans, or induces or promotes ic reports have suggested that exposure to elec- cancer. However, the same review also stressed Health determinants: Nutrition, lifestyle, physical environment and human settlements - 139

that further studies are needed to draw a more carcinogenicity in experimental animals. Thus, complete picture of health risks, especially “possible human carcinogen” means that limit- about possible cancer risks from long-term ed scientific evidence exists suggesting that exposure to low-levels of RF. In order to clarify exposure to ELF fields causes cancer. the extent of the risk, several studies on this Estimates of the Italian population’s exposure to issue are in progress including a major investi- electromagnetic fields ≥0.2 mT have been gation by WHO/IARC on central nervous system made for ELF fields, both due to residence in cancers and exposure to radio frequency fields. the proximity of power lines and to the use of The results of this study are likely to prove rele- electric appliances and the configuration and vant for policy making following concerns position of household electrical wiring. raised by episodic reports on the long term There are about 306 000 people resident in the effects of RF exposure. proximity of 132-380 kV power lines, corresponding to 0.54 % of the total Italian popula- 3.2.2 Extremely Low Frequency Fields (ELF) tion (Anversa et al., 1995). The preliminary results of a large study on childhood leukemia Naturally occurring 50/60 Hz electric and mag- indicate an indoor exposure ≥0.2 mT due to the netic field levels are extremely low and are of use of electric appliances and the configuration the order of 0.0001 V/m, and 0.00001 µT and position of household electrical wiring respectively. Human exposure to ELF fields is ranging from 1 to 10% of the households. On primarily associated with the generation, trans- the basis of these exposure assessments and of mission and use of electrical energy. an estimate of the level of risk for childhood The US National Institute of Environmental leukemia, Lagorio et al. have calculated that Health Sciences (NIEHS) completed its 5-year each year there could be as many as 1.3 (95% RAPID Programme which replicated and confidence interval: 0 - 4.1) extra cases in Italy extended studies reporting effects with possible of childhood leukemia associated with living health implications, in addition to conducting close to power lines and 26.7 cases (95% con- further studies to determine whether there fidence interval: 3.9 - 57.3) associated with actually was any health consequence from ELF exposure at home (Lagorio et al., 1998). These field exposure. In June 1998, NIEHS convened figures correspond respectively to 0.3% and to an international Working Group to review the 6.1% of the total 432 new cases of childhood research results, and the NIEHS international leukemia occurring each year in Italy. panel concluded, using criteria established by the International Agency for Research on Can- 3.3 Water cer (IARC), that ELF fields should be considered a “possible human carcinogen” (NIEHS, 1998). 3.3.1 Drinking water “Possible human carcinogen” is the weakest of three categories (“carcinogenic to humans”, Advances made in water management over the “probably carcinogenic to humans” and “pos- centuries underpin improvements in health and sibly carcinogenic to humans”) used by IARC to development across the European Region. classify potential carcinogens, on the basis of World wide, the availability of suitable water is available scientific evidence. IARC has two fur- the first concern of populations in pursuit of ther classifications of scientific evidence: “prob- health and development. ably not carcinogenic to humans” and “not Access to drinking water may be restricted by classifiable”. “Possible human carcinogen” is a various means. The most significant in Europe classification used to denote an agent for which relate to dependence on non-piped supplies there is limited evidence of carcinogenicity in (e.g. wells or boreholes supplying local residents humans and less than sufficient evidence of with groundwater, which is common in rural 140 - Health determinants: Nutrition, lifestyle, physical environment and human settlements

areas) and the discontinuity of piped supplies. In Italy, 97.8% of municipalities receive water The latter is often connected with dependence from an aqueduct. More than 99% of houses upon inefficient resource protection and ineffi- in cities receive piped water. However, only cient water treatment and distribution system two thirds of the population receive sufficient maintenance. Social and economic barriers to water supply all over the year: about 13% of access, especially affecting the disadvantaged the Italians do not have sufficient water for 1 proved important in some areas. Discontinuity quarter and about 20% for 2-3 quarters. of piped supply and leakage also impact signifi- These proportions are unevenly distributed cantly upon drinking water quality as this allows throughout the country. The majority of the contaminants to enter the system. In Moldova, populations in the South and Islands do not it is reported that up to 50% of water is lost in have sufficient water supply for at least 1 the distribution systems. In the Ukraine, up to quarter per year (Table VII.7) (Ministry of Envi- 30% of water is lost in the pipelines due to leak- ronment of Italy, 1997). age and there is evidence that the water quality These data are confirmed by the results of a is reduced while it is in the pipelines. Cases of survey carried out by ISTAT on irregularities in acute intestinal infections and typhoid fever the provision of domestic water supply (Table were prevalent in 1996, all of which were asso- VII.8). However, the data indicate an improve- ciated with low quality drinking water. Disconti- ment over time between 1993 and 1996. nuity of supply is experienced in Armenia (on These data alone do not demonstrate the grav- average pumped water is supplied for 2-6 hours ity of the situation. Indeed, in several parts of per day; WHO, 1999d), resulting in microbio- Italy where water is available, its organoleptic logical contamination of the water in the supply characteristics (such as turbidity, colour, odour system and contributing to the rates of enteric and taste) are of low quality. Figure VII.22 diseases in recent years. shows the proportion of Italian families by year The detection systems across the European and geographical area by their water drinking Region for water-borne diseases are generally habits: 42.7% of interviewed families declared poor and only the larger outbreaks are in prac- that they did not drink tap water at home. The tice detected. The probability of the detection of proportion of people who do not drink or rarely a water-borne disease outbreak decreases dra- drink tap water is quite large in all areas: the matically with the number of exposed people. largest proportions of people not drinking tap The proportion of the population connected to water at all is observed in the Islands and the public water supplies varies throughout the North-west. There appears to be a slight Region and can vary between different areas of improvement in 1995 compared to 1994, the same country. Logistic difficulties and although the proportion of people who either increased costs mean that rural populations are do not drinking or drink little tap water is still less likely to receive piped water and house con- on average over 60%. These data are quite nections. Within the European Region (popula- consistent with the figures regarding the con- tions totalling 870 million people), in many sumption of mineral water in Italy, which is the countries up to 90% of the urban population highest of all other EU nations (116 has a home connection to drinking water. How- l/person/year) (WHO-ECEH, 1997). ever, there are notable exceptions, with a few Across the entire WHO European Region, there countries having less than 75% of the urban is a clear difference among countries in the per- population connected. The dichotomy between centage of populations exposed to faecally con- provision for urban and rural populations is best taminated water, high nitrate and fluoride con- illustrated in Moldova where 98% of urban centrations. Microbiological pollution is espe- inhabitants have home connections to water cially prevalent in small supply systems where but compared to only 18% in rural areas. location, available facilities and financial con- Health determinants: Nutrition, lifestyle, physical environment and human settlements - 141

Table VII.7: Population availability of drinkable water in Italy by geographical area 1996.

POPULATION WITH ENOUGH WATER POPULATION WITH NOT ENOUGH WATER IN A QUARTER IN 2 OR MORE QUARTERS ABS. VALUE % ABS. VALUE % ABS. VALUE % North-West 13 028 433 91.07 937 130 6.55 339 723 2.37 North-East 8 073 549 92.15 420 708 4.80 267 306 3.05 Centre 6 966 037 79.82 1 050 888 12.04 710 228 8.14 South 2 769 349 22.18 3 160 332 25.31 6 555 359 52.51 Islands 2 841 201 45.23 739 432 11.77 2 701 404 43.00 TOTAL 33 678 569 66.61 6 308 490 12.48 10 574 020 20.91

Source: Ministry of Environment of Italy, 1997.

Table VII.8: Percentage of people declaring that there were irregularities in the water supply on the part of the distribution services in different areas of Italy

YEARS NORTH-WEST NORTH-EAST CENTRE SOUTH ISLANDS ITALY

1993 7.9 6.7 15.5 34.5 41.2 18.7 1994 8.1 5.3 13.4 21.5 42.9 15.5 1995 7.8 6.6 12.0 21.0 38.3 14.7 1996 8.4 5.5 10.1 17.6 24.2 12.0

Source: ISTAT, 1998c.

Figure VII.22: Families drinking tap water at home in Italy - 1994-1995.

Source: ISTAT, 1998c. 142 - Health determinants: Nutrition, lifestyle, physical environment and human settlements

straints may restrict monitoring and treatment. drinkable water (Campania plan) (Ministry of Differences in the proportion of drinking water Environment of Italy, 1997). samples exceeding national standards for total As for the contamination with organo-halo- and faecal coliforms between public and pri- genated compounds, it has been estimated vate supply (usually wells or boreholes supply- that 5% of the Italian population is served by ing local residents with groundwater supplies) water containing up to 50 µg/l of these sub- are clearly illustrated (Figure VII.23). stances (WHO-ECEH, 1997). Groundwater sources, particularly those fed by percolation from intensively farmed agricultural 3.3.2 Recreational Water land, are vulnerable to contamination by nitrates. The increasing use of artificial fertilis- A variety of hazards to human health may be ers, the disposal of wastes and changes in land encountered in recreational water environ- use are the primary factors responsible for the ments, including microbiological pollution, steady increase in nitrate levels in groundwater exposure to toxic algal products and occasional supplies over the last twenty years. exposure to chemical pollution. However, this The Republic of Moldova reports that half of should not cancel the considerable positive the drinking water supplies from groundwater effects on health and well-being of users of in the Prut basin have nitrate concentrations recreational waters. in excess of 45 mg/l. Nitrates may arise from Data on the microbiological quality of recre- run-off from agricultural land and other ational waters is collected in some countries, sources, such as municipal sewage. In many principally for compliance assessment by regu- countries, substantially more nitrogen is latory agencies. EU Member States cooperate applied to farmland than removed with the to produce an annual assessment of bathing harvested crops and this surplus represents a water quality but, despite many attempts to risk to groundwater quality (WHO, 1999d). collate and compare data from different loca- Nitrate concentrations in groundwater have tions (nationally or internationally), the quality been shown to be increasing in some areas of of such data has severe limitations regarding its the Netherlands and Denmark by 0.2-1.3 mg/l value in assessing hazards to human health, pri- per year. In Slovenia, 50% of sampling sites marily due to different approaches to analysis, show concentrations greater than 25 mg/l poor inter-laboratory comparability, differences and in Romania results from more than 30% between countries as to the number of waters of sampling sites exceed 50 mg/l. Nitrate lev- monitored, sampling frequencies and variations els are currently above maximum permissible in temporal conditions. As a result, all of these levels in 76% of wells in Belarus, with con- constraints make comparisons between coun- centrations up to 600 mg/l. For several tries very difficult indeed. In the EU, the quality decades groundwater nitrate concentrations of freshwater sites identified for bathing is con- increased, but recent trends are unclear and siderably worse than those of coastal sites, some countries in Eastern Europe may be sig- although the overall quality trend appears to be nificantly influenced by changes in agricultur- improving (Figure VII.24). al application regimes in response to econom- It has been estimated that microbiological con- ic constraints. Nitrate contamination is wide- tamination of bathing waters, primarily in the spread in Italy and affects particularly shallow Mediterranean, is responsible for over two mil- groundwater sources of the plains of Campa- lion cases of gastrointestinal diseases annually. nia, the Salento peninsula and the basins of The 1999 report on Italian bathing waters shows rivers such as the Esino, Musone and Potenza that over 4 900 Km of coastal waters were in the Marche Region. In some cases, this con- reported as being suitable for bathing in 1998, tamination exceeds the 50 mg/l limit for whereas 447.5 Km (i.e. 6.1% of the total coast- Health determinants: Nutrition, lifestyle, physical environment and human settlements - 143

Figure VII.23: Samples exceeding the drinking water standards for faecal coliforms in selected European countries 1995.

Source: WHO, 1999d.

Figure VII.24: Sea and freshwater sampling points throughout the EU complying with the standard levels for total and faecal coliforms - 1992-1997.

Source: WHO, 1999d. 144 - Health determinants: Nutrition, lifestyle, physical environment and human settlements

line) were reported as being either temporarily or Concern over waste collection and waste treat- permanently unsuitable for bathing (Ministry of ment in urban areas reported in a WHO survey Health of Italy, 1999b). The highest percentage was expressed by 96% of respondents from the of coastal waters unsuitable for bathing for rea- CCEE, 81.2% from the NIS and 56.2% from the sons relating to water quality (i.e. due to pollu- EU (WHO, 1999d). In 1995, waste production in tion) was recorded in Lazio (19.7%), Campania European cities ranged from 260 kg per capita (19.0%), Calabria (7.4%) and Marche (6.8%). per year in Nuremberg and Oslo to 500 kg per The other Regions present values which are capita per year in Brussels, Gothenburg, Leipzig, lower than the national average. However, if the Stockholm and Vilnius. above data are further broken down, most of If not properly disposed wastes can contami- the stretches of coastal waters unsuitable for nate the soil and water sources. Methane ema- bathing are found in the provinces of Caserta nating from landfill sites represents a fire and (43.3%), Roma (34.1%), Napoli (20.4%), Viter- explosion hazards. However, if treated ade- bo (19.2%), Macerata (18.1%), Crotone quately, it could also be a potential fuel source. (17.9%), Pescara (16.0%), Bari (15.9%), Salerno Airborne emissions in composting facilities and (12.0%), Palermo (11.6%), Pisa (10.2%), Cal- waste treatment plants have been identified as tanisetta (10.0%), Ascoli Piceno (9.9%), Genoa a health risk to waste treatment workers. (9.2%), Latina (7.8%), Chieti (7.0%), Cosenza Uncollected wastes are an important cause of (6.5%), Catanzaro and Catania (6.1%). The con- deterioration of well-being and the living envi- siderably high percentage of samples failing to ronment. Data from a survey carried out by meet the bacteriological standards indicates that ISTAT on the “dirtiness” of their surrounding pollution from sewage is largely responsible for neighbourhoods show that around 30% of the current quality problems of some coastal families in Italy describe their neighbourhoods bathing waters in Italy. as being “very” or “fairly” dirty. The situation is As far as the water in Italian lakes and rivers is better in the North of Italy than in the Centre concerned, 14% of samples did not meet the and South. On average, there appears to be a quality standards for all the parameters in slight improvement, although data seem to 1998. Here, too, did untreated sewage have a indicate a deterioration in the Centre of the major role to play (Ministry of Health of Italy, country (ISTAT, 1998c). 1999b). Table VII.9 summarises the distribution of several indicators of waste production in Europe. 3.3.3 Wastewater Over the time period 1990-1995/97, the amount of waste production per capita pre- For a detailed analysis of the wastewater and sents an uneven picture: a decrease was sewage water treatment plants in Italy, which observed in Sweden, Finland, Luxembourg, are deemed to be largely unsatisfactory, see the Germany and Austria while an increase was WHO/ECEH report “Ambiente e Salute in Italia” reported in the other EU countries. In Italy, reg- (WHO-ECEH, 1997). ulations currently in force refer to urban wastes (RU) and special wastes (RS); the latter includes toxic and noxious wastes. The global produc- 3.4 Waste generation, collection and treat- tion of wastes in Italy, based on data from ment Regions, corresponds to 63.6 MTs/year for 1993 and 1994, 22.7 MTs of which were urban There is growing public concern across the wastes, 4.2 MTs attributed to urban wastes, whole European Region about the possible neg- 19.2 MTs special wastes, 2.7 MTs toxic and nox- ative impacts on the environment and health of ious wastes, 14.3 MTs inert wastes and 200 waste generation, management and treatment. thousand tons were hospital wastes. Health determinants: Nutrition, lifestyle, physical environment and human settlements - 145

Figure VII.25: Urban waste differential collection in Italy by Region – 1997.

<<1.5% 1.5% 1.5%1.5% - 3% -3% 3%3% - 6% -6% 6%6% - 10% -10% 10%10% - 20% -20% 20%20% - 40% -40%

Source: ANPA, 1999.

The total amount of urban wastes per capita in wastes in Italy takes place mainly through landfills Italy is slightly below the European average, as (79.9% of the total production of urban wastes), reported in Table VII.9. On the other hand, the while incineration was used for 6.6% of urban recycling rate of paper and glass is respectively wastes and 9.4% was processed to compost and well below the European average. Overall, the fuel production. Thirty-eight incinerators are cur- proportion of urban wastes recycled is only 9.4% rently operating in Italy (ANPA, 1999). and varies markedly among Italian Regions: 17% As far as special and toxic-noxious wastes are in the North, 6.4% in the Centre and 1.4% in the concerned, some Italian data are provided below South (Figure VII.25). The final disposal of urban according to their composition and origin. 146 - Health determinants: Nutrition, lifestyle, physical environment and human settlements

Table VII.9: Urban waste (RU) production in the European countries with respect to some selected socio-economic macro- indicators.

RU TOTAL RU PER CAPITA RU TOTAL PAPER AND GLASS POPOLATION RESIDENTIAL EU COUNTRIES PRODUCTION PRODUCTION PRODUCTION PER CARDBOARD RECOVERED DENSITY POPULATION 1997* 1995** SURFACE UNIT RECOVERED 1997 (%) (UNITS X KM2) 1996** (TX1000/YEAR) [KG/(AB.*YEAR)] 1997 (T/KM2) 1997 (%) (UNITS X 1000) Austria 4 110 556 47.87 65 88 93.5 8 055 Belgium 5 028 474 164.76 12 75 331.5 10 143 Denmark 2 864 520 66.48 44 70 120.8 5 251 Finland 2 100 351 6.21 57 62 15 5 117 France 34 700 573 63.79 40 52 106.4 58 256 Germany 43 486 319 121.91 70 79 228.3 81 818 Greece 3 000 310 22.79 31 26 79.2 10 465 Ireland 1 325 437 19.23 12 38 51.8 3 616 Italy 26 605 462 88.30 30 34 189.8 57 563 Luxembourg 193 414 74.63 n.a. n.a. 156.1 413 Netherlands 8 726 596 212.68 62 82 374.9 15 494 Portugal 3 500 356 38.08 37 44 107.7 9 921 United Kingdom 35 000 608 144.78 40 23 241.5 58 694 Spain 15 307 361 30.32 42 37 77.6 39 242 Swede 3 200 446 7.79 54 76 21.4 8 838 EU total 189 144 372 884 EU average 507 48.7 53.0 116.3

* Data for Italy and Luxembourg refer to 1997; for all the other countries, most recent available data. ** Elaboration ANPA on EUROSTAT data.

Source: ANPA, 1999.

Wastes with asbestos: materials containing • Of 620 000 tons of exhausted oils on the asbestos which needs to be disposed in the national market each year, 177 000 are collect- short-medium term amount to 30 MTs, 80% of ed through 70 ad hoc collectors. which consists of cement asbestos and 20% by • As far as used vegetable fats and oils are con- friable asbestos. All handling of this material is cerned, the market inflow per year is 1 400 000 regulated under the provisions laid down by ton, 20% of which are collected by the appro- Law 257/92 and Law 22/97. priate consortium. PCBs (Polychlorobipheniles): 150 000 trans- • As for batteries and accumulators, the nation- formers containing PCB are currently in use in al production as exhausted material is 175 000 Italy. In compliance with EC Directive 96/59, tons per year, 95% of which were collected. they should be quickly replaced. • As for polyethylene wastes, the market inflow Exhausted mineral oils; used vegetable fats and corresponds to 1 700 000 tons per year, only oils; batteries and electrical accumulators; poly- 30% of which are being collected. ethylene wastes: collection and recycling of Agricultural wastes: about 2 500 000 farms pro- these wastes is mandatory and carried out by duce agricultural wastes in Italy. Widespread “ad hoc” companies. submission of farmland on the territory results Health determinants: Nutrition, lifestyle, physical environment and human settlements - 147

Figure VII.26: Level of noise in some Italian cities – 1996.

Source: Ministry of Environment of Italy, 1997.

in a rather poor waste management system, 65 dB(A). Residential/inhabited areas exposed particularly in the South of Italy. to noise levels between Leq 55 dB(A) and Leq Final disposal of special wastes, including toxic 65 dB(A) are undesirable from the health and noxious ones, is confronted with a number stand point and exposure to noise levels of difficulties (see the WHO/ECEH Report above Leq 75 dB(A) is unacceptable because it “Ambiente e Salute in Italia”). can cause loss of hearing. Today, many human settlements in the European Region have 3.5 Noise ambient noise that exceeds these levels. About 450 million people are exposed to daily The relationship between noise and health is ambient noise levels above 55 dB(A), about neither clear nor straightforward. Excessive 113 million are exposed to ambient noise lev- noise can have a wide range of effects on els above Leq 65 dB(A) and about 9.7 million individuals, ranging from disturbance to citizens are exposed to noise levels above 75 increased stress, loss of sleep, increased blood dB(A). pressure, headaches and permanent damage The main sources of acoustic disturbances are to hearing. Studies of the effects of noise on road, rail and air traffic, recreational activities health and well-being indicate that the out- and industry. There is a growing amount of door level of noise should not exceed a day- evidence that road traffic noise is the most time Leq (Equivalent Sound Pressure Level) of widespread source of nuisance in Europe. In 148 - Health determinants: Nutrition, lifestyle, physical environment and human settlements

large European cities, the number of inhabi- mates are given about noise from neighbours. tants exposed to excessive levels of noise is In Bulgaria, between 40% and 50% of the res- two or three times greater than national aver- ident population in urban areas live with exces- ages. sive noise levels. In Switzerland, it is estimated Despite the limited data and information about that 30% of the total population are confront- noise in human settlements, there is a growing ed by noise levels from road traffic that exceed amount of evidence that noise has become a prescribed levels. concern for increasing numbers of citizens and A study carried out by the Italian Ministry of national authorities in Europe. According to a Environment shows that in all the Italian cities study carried out by WHO (WHO, 1999d), con- monitored, noise levels are above the existing cern over noise in residential areas was standards both at daytime and at night (Figure expressed by 75% of respondents to a ques- VII.26). tionnaire from the EU, 64% from the CCEE and 44.8% from the NIS. Noise has been recog- nised as an important component of environ- 4. HUMAN SETTLEMENTS mental health in several European countries. In Sweden, 5% to 10% of the population are dis- Despite lower levels of investments by govern- turbed by noise from traffic, whereas 2% to ments in the housing sector during the 1990s, 6% suffer from noise from neighbours and 1- there is no evidence that housing standards and 2% suffer from noise created by industrial pro- occupancy conditions have declined across the duction functions. In Hungary, the situation is European Region. Housing contributes to the much worse: about 50% of the population are well-being of inhabitants and inadequate hous- disturbed by noise from road traffic, whereas ing conditions may contribute to illness. Basic noise from industrial sites and service activities sanitary services – the availability of a piped disturbs about 5% of the population; no esti- water supply, sewerage disposal – and the

TARGET 13 – HEALTH21

By the year 2015, people in the Region should have greater opportunities to live in healthy physical and social environments at home, at school, at the workplace and in the local community.

In particular: 13.1 the safety and quality of the home environment should be improved, through increased personal and family skills for health promotion and protection, and the health risks from the physical home environment should be reduced; 13.2 people with disabilities should have substantially improved opportunities for health and access to home, work, public and social life in accordance with the United Nations Standard Rules on the Equalization of Opportuni- ties for Persons with Disabilities; 13.3 home and work accidents should be reduced as specified in target 10; 13.4 at least 50% of children should have the opportunity of being educated in a health-promoting kindergarten, and 95 % in a health-promoting school; 13.5 at least 50% of cities, urban areas and communities should be active members of a healthy city healthy community network; 13.6 at least 10% of medium- and large-sized companies should commit themselves to practising healthy company principles. Health determinants: Nutrition, lifestyle, physical environment and human settlements - 149

absence of damp, mold and fungi in building higher in the South and Islands compared to structures, are essential for health promotion in the Centre-North. As far as the quality of the human settlements. Although these basic housing available to Italian families is con- requirements are more common in western cerned, Figure VII.28 reports the proportion of European cities and towns, they are still absent people indicating that their homes were in or defective in many urban and rural Regions of “bad” condition by geographic area of resi- the CCEE and NIS countries. dence. Again, overall housing conditions are The availability and affordability of habitable perceived to be worse in the South (7.9%) and floor space is a crucial dimension of the qualita- Islands (9.7%) as compared to the other parts tive aspects of housing. There are major differ- of the country (range 4.6%-6.4%). In addition, ences in the amount of floor space per inhabi- data indicate an improvement of housing con- tant in Europe, especially between Western and ditions over time in North-West, Centre and Eastern European countries. Data on the hous- South of Italy, while a slight deterioration is ing size and occupancy conditions in Central reported in 1996 compared to 1995 in the and Eastern European countries show a housing North-East and Islands. deficit – the difference between the number of Homelessness is increasing throughout the households and the number of housing units – WHO European Region and all its health conse- that varies from 7.5% in the Baltic States to quences, which are strongly related to poverty, 20% in the Russian Federation. Only Bulgaria remain an urgent problem. The Italian Survey of and Hungary have overall occupancy conditions Extreme Poverty showed that in Italy in the early in which there is less than one person per room. 1990s, an estimated 56 000 people were In Eastern Europe there is a total of about 20 m2 homeless on any one day of the year or 78 000 of habitable floor space per person, whereas in over the course of the year, i.e. 1-1.5 per 1 000 the Russian Federation it is only 16.4 m2. Recent population, the lowest rate in the EU. However, data for Western European countries indicate these figure likely apply to cases of extreme the availability of 33.5 m2 in Italy in 1997 and 45 homelessness only. Other sources estimate that m2 in Norway in 1993. 150 000-220 000 people may be termed In 1985, some 2% of the population in Italy “homeless” when immigrants, gypsies and lived in houses with no inside toilet and 7.5% mental patients are included. The correspond- had no shower or bathroom (Avramov, 1995). ing rate of 3-4 homeless per 1 000 population In 1993-1996, an average of 11.8-16.7% of is closer to the EU average (5.2 per 1 000) and families reported they were living in “houses to the rates observed in countries such as which were too small for their needs” (Figure France, Germany or the United Kingdom VII.27): the proportion of “too small” houses is (Avramov, 1995). 150 - Health determinants: Nutrition, lifestyle, physical environment and human settlements

Figure VII.27: Italian families reporting that their house was “too small”* - 1993-1996.

Source: ISTAT, 1998c.

Figure VII.28: Italian families reporting that their house was “in bad conditions” - 1993-1996.

Source: ISTAT, 1998c. CHAPTER VIII

EQUITY IN HEALTH

CONTENTS 1. POVERTY...... 152

2. INEQUALITIES IN HEALTH...... 152 2.1 Mortality ...... 154 2.2 Morbidity ...... 158 2.3 Risk factors ...... 159 152 - Equity in health

1. POVERTY 2. INEQUALITIES IN HEALTH

Poverty - whether defined by income, socio- A recent large European international study economic status, living conditions, educational compared mortality and morbidity (as mea- levels or by other indicators - is the largest sin- sured by self-perceived health) in 9 and 11 gle determinant of ill health. Living in poverty is European countries, respectively. Mortality data correlated with higher rates of mortality, mor- refer to the period 1980-1990, while morbidity bidity, use of tobacco, alcohol and illegal drugs, to the period 1985-1992. All comparisons were antisocial behaviour and violence, as well as carried out taking a “broad” upper socio-eco- with an increased risk from unsafe food and a nomic group as reference and calculating the wide range of physical complaints. Increasingly risk of the outcome being studied for the large numbers of people in European societies “broad” lower socio-economic group (Macken- today risk experiencing poverty at some time in bach et al., 1997). Both mortality and morbidi- their lives. Even in affluent societies, health ty were always higher in the lower socio-eco- inequalities increase with widening socio-economic group, with risks ranging between 1.3 nomic disparities in a social gradient which cuts and 1.7 for mortality and between 1.5 and 2.6 across all socio-economic groups, society as a for morbidity (Figures VIII.2 and VIII.3). whole and indeed throughout life itself (Figure The risk associated with socio-economic status VIII.1). in Italy lies in the mid-range of the distribution

Figure VIII.1: Percentage of population below the income poverty line* in selected European countries – 1989-1994.

* Poverty is measured at 50% of the median adjusted available personal income

Source: UNDP, 1998. Equity in health - 153

TARGET 2 - HEALTH21

By the year 2020, the health gap between socioeconomic groups within countries should be reduced by at least one fourth in all Member States, by substantially improving the level of health of disadvantaged groups.

In particular: 2.1 the gap in life expectancy between socioeconomic groups should be reduced by at least 25%; 2.2 the values for major indicators of morbidity, disability and mortality in groups across the socioeconomic gradient should be more equitably distributed; 2.3 socioeconomic conditions that produce adverse health effects, notably differences in income, educational achievement and access to the labour market, should be substantially improved; 2.4 the proportion of the population living in poverty should be greatly reduced; 2.5 people having special needs as a result of their health, social or economic circumstances should be protected from exclusion and given easy access to appropriate care.

Figure VIII.2: Relative risk of mortality for men from low socio-economic class aged 25-69 in selected EU countries – 1985-1992.

Source: Mackenbach et al., 1997. 154 - Equity in health

Figure VIII.3: Relative risk of morbidity for men from low socio-economic class aged 25-69 in selected EU countries – 1985- 1992.

ource: Mackenbach et al., 1997.

for both mortality and morbidity. It is interesting exposure to risk factors among the better-off to note that inequalities in mortality in the (Valkonen, 1994). Nordic countries were determined by a socio- Similar to other countries, Italy presents signifi- economic gradient for cardiovascular mortality, cant inequalities in health conditions: the less whereas in Switzerland, Italy and Spain such a well-off people, specific social groups and geo- gradient is not evident. This difference can be graphic areas are more exposed to death, dis- explained by a different distribution of risk fac- eases, disabilities and unhealthy lifestyles. The tors, such as smoking, which showed a larger causes for these disparities originate in the pop- gradient than the average in Sweden and Nor- ulation’s living and working conditions, social way compared to Switzerland, Italy and Spain. income and welfare status, as well as lifestyles Differences in timing of the cardiovascular dis- and access to health care. ease epidemic, as well as the presence of other risks or protective factors have been postulated 2.1 Mortality (Kunst, 1996). In recent years, global health inequalities in The results of national (ISTAT, 1990) and local Europe have not diminished and, in some cases (in Torino [Costa et al., 1994] and Toscana have even become worse, possibly as a conse- [Toscana Region, 1998]) studies and surveys quence of better living conditions and less (such as that carried out by the Lazio Region Equity in health - 155

Epidemiology Unit) (Michelozzi et al., in press) higher than among people of the same age show important social differences in mortality from the South. Among young women, the in the 1980s and early 1990s. lower the level of education, the higher the The ISTAT study examined mortality occurring mortality, with no significant differences associ- during the first six months after the 1981 pop- ated to the geographical area of residence. The ulation census in people aged between 18 and situation is different for individuals of 55 years 74 years. This made it possible to correlate of age or more. A social gradient is observed in deaths with the socio-economic condition of Southern Italy among men. This difference has each subject. This study indicates that if mortal- been attributed to a variety of factors, including ity among people with low levels of education life experience (such as war or occupational his- had been similar to that observed among indi- tory), as well as the characteristics of risk viduals with the highest levels of education, behaviours, such as smoking, lifestyle or diet. there would have been 40 000 less deaths in Social gradients of mortality are also observed Italy among people 18-74 years of age. This for some causes of death, such as specific can- study also assessed social differences by age cers among males and females in Italy (Figures and main area of residence (North vs. South) VIII.5a and VIII.5b). (Figure VIII.4). The Turin study has followed the population of Young men aged less than 55 years from Turin since 1971 through two subsequent cen- Northern Italy present differences in mortality suses in 1981 and 1991. This allowed for a rates due to social class as measured by their more detailed assessment of the factors associ- educational level, which is at least twofold ated with inequalities. Table VIII.1 shows life

Figure VIII.4: Relative risk of mortality in Italy by level of education, sex, age, geographical area (reference subjects with university degree) – November 1981-April 1982.

Source: Faggiano et al., 1993. 156 - Equity in health

Figure VIII.5a: Relative risk of mortality in Italy by level of education and cause of death among men between 18 and 74 years of age – November 1981-April 1982 (RR=1 for university graduates).

Source: Faggiano et al., 1993.

expectancy for males and females by age class people or those employed in public administra- and education level (life expectancy of people tion. with a university degree is taken as reference). A more recent study carried out in Livorno and Among adult men and women (30-59 years), Firenze (Toscana) investigated the relationship differences of life expectancy by social class between mortality rates for all causes of death have decreased with time overall, but they occurring in the period between 1987-1995. In have increased in the lower social classes, par- Livorno, life expectancy at 35 years is 4.5 years ticularly in men. For older men and women the longer for men and 2.5 for women with upper situation deteriorated over time, particularly secondary level of education and is higher than for those belonging to the lowest social class that for people with no formal education. (Costa, 1998). Between 1991 and 1995 Florence showed a Another interesting finding is the analysis of gap of 3 years both for men and women mortality by occupation. Standardized mortality among the same social classes. In addition, rates for a number of occupations are shown in both cities have high mortality rates among the Table VIII.2: manual workers have higher mor- unemployed: in this group, mortality for all tality rates in comparison with professional causes is twice as high compared to employed Equity in health - 157

Table VIII.1: Life expectancy for males and females by age, class and educational level (University degree as reference).

GENDER AGE PERIOD DIFFERENCE IN LIFE EXPECTANCY (YEARS) AT 35 YEARS OF AGE

WHOLE HIGH JUNIOR ELEMENTARY LITERATE OR POPULATION SCHOOL HIGH SCOOL ILLITERATE

Men 30-59 1971-75 –0.71 –0.33 –0.55 –0.86 –1.23 1981-85 –0.54 –0.26 –0.47 –0.77 –1.63 1991-95 –0.41 –0.11 –0.43 –1.11 –1.84

Women 30-59 1971-75 –0.25 –0.06 –0.26 –0.23 –0.42 1981-85 0.17 0.25 0.21 0.14 –0.48 1991-95 –0.12 –0.04 –0.10 –0.26 –1.02

DIFFERENCE IN LIFE EXPECTANCY (YEARS) AT 65 YEARS OF AGE Men 60-74 1971-75 –0.33 –0.17 –0.39 –0.45 1981-85 –0.69 –0.68 –0.75 –1.38 1991-95 –0.43 –0.31 –0.64 –0.99

Women 60-74 1971-75 –0.28 0.04 –0.30 –0.39 1981-85 –0.33 –0.09 –0.34 –0.64 1991-95 –0.34 –0.35 –0.35 –0.67 Source: Costa et al., 1998.

Figure VIII.5b: Relative risk of mortality in Italy by level of education and cause of data among women between 18 and 74 years of age – November 1981-April 1982 (RR=1 for university graduates).

Source: Faggiano et al., 1993. 158 - Equity in health

Table VIII.2: Standardized death rate and number of deaths in Turin in men aged between 18 and 64 according to profession (10 with the highest and 10 with the lowest mortality) - 1981-1989.

PROFESSION SDR* High mortality

Waiters, cooks ...... 149 Road workers ...... 147 Porters ...... 143 Street cleaners ...... 139 Blacksmiths ...... 137 Electricians ...... 129 Foundry workers ...... 126 Shopkeepers ...... 120 Guards ...... 112 Unskilled workers ...... 106

Low mortality Officers ...... 59 Bankclerks ...... 64 Executives, employees of electricity power stations ...... 64 Professional people ...... 75 Medical doctors ...... 77 Executives, employees of iron industries ...... 77 Technicians ...... 80 Public administration executives ...... 80 Executives, employees of mechanics industries ...... 82 Teachers ...... 84

* mortality of the whole population = 100

Source: Costa et al., 1994.

people. Also, life expectancy at 35 years is 3 total mortality increased in the more recent peri- years higher for employed people than for the od, due to a decrease in mortality rate in the unemployed. more affluent group (–8.2% in males and Recent data for Rome confirmed the observa- –3.1% in females) and to an increase among the tions made in Torino and Toscana. Social class less well off (+1.3% in males and +2.6% in was classified in 4 groups on the basis of educa- females). The relative risk comparing level 4 with tion, occupation, characteristics of dwelling and 1 increased in the second period, from 1.13 to socio-demographic variables. In the period 1.24 in males and from 1.04 to 1.10 in females. 1991-1995, mortality for all causes in level 4 compared to level 1 was 19% higher for men 2.2 Morbidity and 7% for women, particularly for people aged 15-44. A comparison of data for 1993-95 with Social differences in morbidity can result from those for 1990-92 shows that inequalities in social variations affecting the incidence of dis- Equity in health - 159

ease and its various determinants, as well as 2.3 Risk factors from the possibility of having access to appropriate cures and treatments. Inequalities in health may be partially explained Registers for malignant neoplasms are good by the differences in exposure to well-known sources of information to estimate inequalities risk factors. Time series researches conducted in the incidence and survival rates of cancer. by ISTAT on the status of health in Italy (ISTAT, The Turin study analyzed social differences in 1994a) show for instance that the prevalence malignant neoplasm incidence based on the of smoking among men is indirectly propor- Piemonte Cancer Register. Tables VIII.3a and tional to their level of education (Table VIII.4). VIII.3b show the results of a neoplasm case- The increase in differences over time confirms control study carried out using new cancer the increase in former smokers among people cases diagnosed between 1985 and 1987 and with the highest levels of education. On the linked to socio-economic information derived other hand, smoking habits are more prevalent from the 1981 population census. In men, among well-educated women. there is a socio-economic gradient of all cancer Time trends for the prevalence of chronic bron- incidence and for some specific cancer sites: chitis are inversely correlated to the level of upper digestive tract, stomach, colon, larynx education, especially for men but also for and lung. An inverse relationship was observed women. This observation, together with data for skin cancer. In women, there was a positive on smoking prevalence, indicate that socio-eco- correlation to education for all cancers, with nomic related factors, other than smoking, play lower incidence in low social classes. However, a role in the physiopathological mechanisms a negative gradient was observed for cancer of causing bronchitis. the cervix. The trends in cancer incidence by social class Social conditions are also correlated with sur- may also be partly explained by different vival rate for malignant neoplasms, i.e. a low exposure to risk factors by social class and by socio-economic level is normally associated sex: for instance, alcohol for cancer of the with less favourable rates. Nevertheless, some upper digestive system, smoking for the lung studies conducted using data from Sweden and and larynx, and a low-fibre high-fat diet for the U.K. show that social inequality in mortality the intestine. are much more influenced by inequality in can- A large number of premature cancer deaths cer incidence than in survival rates (Kogevinas (from 5 700 to 8 100) would not have occurred if et al., 1991; Vagero et al., 1987). the prevalence of smokers by education had Another study analyzed the inequalities and been equal to that in the less exposed category; prevalence of chronic diseases by level of educa- the largest life “saving”, in this case, would have tion: the prevalence of many chronic diseases is been among the less educated people (Ponti et always lower for people with a higher level of al., 1994). Moreover, other risk factors associated education. The odds ratios1 for people with only to lifestyle, as well as the use of preventive health primary school education as compared to those services (Ronco et al., 1991; Ferraroni et al., with a high school diploma or university degree 1989; Perucci et al., 1990), are distributed range from a maximum level of 4.76 for cirrhosis according to socio-economic status with higher and 2.32 for chronic bronchitis, to a minimum prevalence among people with low education level of 1.31 for blood hypertension and 1.26 for levels (e.g. physical activity and alcohol consump- kidney stones (La Vecchia et al., 1987). tion) (Arcà et al., 1986; Ponti, 1989).

1 Odds ratio: is the ratio of the odds in favour of getting a disease, if exposed, to the odds in favour of getting a disease if not exposed. It is commonly used as an estimate of the relative risk when the disease is rare. 160 - Equity in health

Table VIII.3a: Odds Ratios for cancer in Turin according to education level – Men. 1985-1987.

UNIVERSITY HIGH JUNIOR HIGH ELEMENTARY P (TREND) DEGREE SCHOOL SCHOOL SCHOOL

All cancers (ICD IX 140-208) no. cases/controls 262/1169 599/2517 1026/4234 2328/8954 Odds ratio 1 1.03 1.04 1.15 0.001 I.C. 95% 0.87-1.22 0.90-1.22 1.00-1.34

Upper respiratory tract (ICD IX 140-150,161) no. cases/controls 20/113 52/281 108/507 298/1015 Odds ratio 1 0.92 1.16 1.71 0.000 I.C. 95% 0.51-1.66 0.68-1.98 1.02-2.88

Stomach (ICD IX 151) no. cases/controls 11/61 28/152 48/232 152/512 Odds ratio 1 0.83 1.02 1.48 0.032 I.C. 95% 0.38-1.84 0.49-2.10 0.74-2.95

Colon rectum (ICD IX 153-154) no. cases/controls 49/111 64/239 114/440 200/914 Odds ratio 1 0.54 0.59 0.48 0.001 I.C. 95% 0.34-0.86 0.39-0.88 0.33-0.71

Larynx (ICD IX 161) no. cases/controls 8/62 28/127 60/251 129/462 Odds ratio 1 1.45 1.83 2.23 0.015 I.C. 95% 0.60-3.47 0.83-4.08 1.02-4.87

Lung (ICD IX 162) no. cases/controls 31/278 100/508 223/910 575/2024 Odds ratio 1 1.66 2.03 2.47 0.047 I.C. 95% 1.07-2.57 1.36-3.04 1.67-3.65

Skin (ICD IX 173) no. cases/controls 50/158 97/315 135/539 239/1072 Odds ratio 1 1.05 0.81 0.72 0.013 I.C. 95% 0.70-1.57 0.56-1.18 0.50-1.03

Prostate (ICD IX 185) no. cases/controls 20/49 29/88 30/162 95/395 Odds ratio 1 0.81 0.45 0.66 0.195 I.C. 95% 0.40-1.65 0.23-0.87 0.36-1.19

Bladder (ICD IX 188) no. cases/controls 23/108 58/262 100/404 252/961 Odds ratio 1 1.03 1.10 1.16 0.363 I.C. 95% 0.60-1.79 0.66-1.82 0.72-1.88

Lymphomas, leukemias (ICD IX 200-208) no. cases/controls 15/52 40/161 66/262 101/413 Odds ratio 1 0.81 0.85 0.81 0.705 I.C. 95% 0.40-1.65 0.44-1.64 0.43-1.55

Source: Faggiano et al., 1994. Equity in health - 161

Table VIII.3b: Odds Ratios for cancer in Turin according to education level – Women. 1985-1987.

UNIVERSITY HIGH JUNIORHIGH ELEMENTARY P (TREND) DEGREE SCHOOL SCHOOL SCHOOL

All cancers (ICD IX 140-208) no. cases/controls 129/410 436/1681 942/3321 1944/8410 Odds ratio 1 0.87 0.90 0.76 0.002 I.C. 95% 0.69-1.10 0.73-1.12 0.62-0.94

Upper respiratory tract (ICD IX 140-150,161) no. cases/controls 7/31 21/59 39/178 Odds ratio 1 1.19 0.82 0.438 I.C. 95% 0.43-3.31 0.30-2.24

Stomach (ICD IX 151) no. cases/controls 9/67 22/97 79/279 Odds ratio 1 2.47 2.84 0.086 I.C. 95% 0.93-6.51 1.15-7.01

Colon rectum (ICD IX 153-154) no. cases/controls 15/47 40/148 84/331 214/888 Odds ratio 1 0.78 0.75 0.71 0.314 I.C. 95% 0.38-1.58 0.40-1.42 0.38-1.32

Lung (ICD IX 162) no. cases/controls 26/81 44/162 91/402 Odds ratio 1 0.74 0.62 0.099 I.C. 95% 0.41-1.35 0.35-1.11

Skin (ICD IX 173) no. cases/controls 19/47 45/181 97/328 193/858 Odds ratio 1 0.62 0.79 0.59 0.086 I.C. 95% 0.32-1.17 0.44-1.42 0.33-1.04

Breast (ICD IX 184) no. cases/controls 44/126 161/551 316/1085 589/2684 Odds ratio 1 0.86 0.84 0.66 0.001 I.C. 95% 0.58-1.29 0.56-1.21 0.40-0.96

Uterus Cervix (ICD IX 180) no. cases/controls 10/94 32/131 92/313 Odds ratio 1 1.77 2.33 0.012 I.C. 95% 0.81-3.86 1.09-4.97

Uterus Body (ICD IX 182) no. cases/controls 28/98 50/172 118/515 Odds ratio 1 0.93 0.81 0.862 I.C. 95% 0.54-1.60 0.49-1.34

Lymphomas, leukemias (ICD IX 200-208) no. cases/controls 31/109 53/188 90/400 Odds ratio 1 0.92 0.72 0.283 I.C. 95% 0.54-1.56 0.42-1.23

Source: Faggiano et al., 1994. 162 - Equity in health

Table VIII.4: Odds ratios for the prevalence of smokers and persons affected by bronchitis by level of education as reported by ISTAT surveys on state of health in 1980-1983-1986-1991.

MEN UNIVERSITY HIGH SCHOOLJUNIOR HIGH ELEMENTARY UNEDUCATED DEGREE SCHOOL

Smoking

1980 1(22.4) 1.24 1.37 1.42 1.34 1983 1(20.0) 1.17 1.33 1.41 1.31 1986 1(18.1) 1.17 1.27 1.35 1.31 1991 1(11.8) 1.30 1.50 1.73 1.40

Bronchitis

1980 1(20.0) 1.30 2.00 2.55 3.35 1983 1(20.0) 1.00 1.30 2.20 3.20 1986 1(1.50) 1.47 1.87 3.00 4.53 1991 1(0.80) 1.12 1.25 2.75 7.25

WOMEN

Smoking

1980 1(16.5) 1.05 0.90 0.52 0.31 1983 1(14.1) 0.93 0.99 0.69 0.40 1986 1(14.9) 0.95 0.80 0.60 0.38 1991 1(14.2) 0.94 0.84 0.78 0.54

Bronchitis

1980 1(1.3) 1.23 1.00 1.23 2.08 1983 1(1.2) 1.08 1.17 1.75 2.75 1986 1(0.9) 1.11 1.33 2.00 4.11 1991 1(0.3) 2.00 3.00 3.33 7.67

Source: Buratta et al., 1993. CHAPTER IX

BIOETHICS IN HUMAN HEALTH

CONTENTS 1. NATIONAL ADVISORY BIOETHICS COMMITTEE (NABC) ...... 164 2. ETHICS COMMITTEES AND CLINICAL TRIALS ...... 164 3. BIOETHICS AND EMERGING ISSUES ...... 165 3.1 Biotechnologies ...... 165 3.2 Cloning ...... 165 3.3 Medically-assisted procreation ...... 165 3.4 Genetic tests ...... 165 4. ORGAN AND TISSUE TRANSPLANTS ...... 166 5. CHILDHOOD: A HIGH-PRIORITY AREA ...... 166 6. CARE SERVICES TO TERMINAL PATIENTS ...... 166 164 - Bioethics in human health

In Italy, health issues are at the forefront of ago would have been unthinkable. Consequent- bioethics in order to protect the dignity of human ly, ethics committees have the duty and obliga- beings – especially the ill – and, in spite of the tion to encourage this situation while at the same many difficulties, provide clear-cut rules to pro- time keeping a close eye on its multi-faceted mote medical research and highly-innovative developments. practical applications. The most remarkable innovations recently Many regulations and provisions have been laid implemented in Italy regard the role and status down over the years by the Italian Parliament of independent ethics committees which have and Government to meet the growing and been empowered with a specific competency rapidly changing demands associated with and whose former simple “recommendations” bioethics. have now become “binding resolutions”. These developments have opened the way for an institutionally recognized approach consistent 1. NATIONAL ADVISORY BIOETHICS COM- with the spirit of the INHS, which is committed MITTEE (NABC) to make the quantum leap necessary to upgrade the services it provides, including Following the recommendation of the Parliamen- increased patient participation, as well as tary Assembly of the Council of Europe, the res- boosting bio-medical research. olution of the European Parliament and the reso- Ethics committees are independent bodies, usu- lution adopted by the Italian Chamber of ally set up under the umbrella of either health Deputies on 5 July 1998, the National Advisory care structures or scientific research institutions Bioethics Committee (NABC) was established in involved in performing clinical trials. These have Italy by the Presidential Decree of 28 March an interdisciplinary nature given that they consist 1999. of members of the medical profession as well as Since then, the NABC has been working active- “lay” people, i.e. clinical doctors, pharmacolo- ly and has issued a number of recommenda- gists, bio-statisticians, legal experts, bio-ethicists, tions, backed up by detailed reports dealing nurses, GPs and voluntary association representa- with genetic treatments, the definition and tives. ascertainment of human death, biotechnolo- The committees’ work, inspired mainly by the gies, terminal patients, organ transplants, the Helsinki Declaration and the Recommendations establishment of ethics committees, prenatal of the Good Clinical Practice laid down in the diagnoses, drug experimentation, patentability European Community Regulations, is geared to of living bodies, assisted insemination, human guaranteeing the rights, safety and well-being of genomes, environment, end-of-life bioethics, the individuals participating in a clinical study. The cloning, vaccinations and organ transplants committees study and approve experiments and from anencephalic infants. related protocols, as well as the eligibility and competency of the experimenters. In addition, they evaluate the feasibility of the trial in the spe- 2. ETHICS COMMITTEES AND CLINICAL TRI- cific health structure and the correctness of the ALS recruitment procedures of voluntary subjects (patients and control). In Italy, regulations have recently been issued to The National Advisory Ethics Committee for strengthen the framework within which clinical Drug Clinical Trials at the Italian Ministry of trials are carried out. Health works along similar lines. The National Biological and pharmacological research is con- Committee’s opinion is vital when judging the tinually breaking new grounds and as a result most innovative medicines and assessing multi- there are now opportunities that only a few years centre trials of interest to the entire country. Bioethics in human health - 165

3. BIOETHICS AND EMERGING ISSUES several times. However, the situation may change in the near future in view of the recom- 3.1 Biotechnologies mendation, issued in May 1998, in which the National Biosafety and Biotechnology Commit- Regarding the issue of legally protecting biotech- tee called for a total ban on human cloning as nological inventions, Italy has decided along with well as for clear-cut rules to regulate animal The Netherlands to appeal against EC Directive cloning. No. 44/1998 of 6 July 1998 before the High Court in the Hague. However, Italy wishes to 3.3 Medically-assisted procreation establish a legal framework for the following key- issues: banning the sale of any part of the human In spite of the many different bills proposed body; protecting human embryos; protecting the during the past few years, medically assisted individual’s and the community’s health; conserv- procreation is becoming a very critical issue in ing the environment; safeguarding bio-diversity Italy due to the lack of adequate regulations. with special reference to the rights of developing Considering the increase in irregular behaviour countries; promoting public research in the field and the diffusion of misleading advertising and, of biotechnologies and upgrading the informa- above all, because of the lack of specific regu- tion flow intended for consumers. lations, the Minister of Health issued an ordi- Moreover, recently the National Biosafety and nance in 1997. This banned individuals and Biotechnology Committee developed and for- organizations from accruing profits deriving warded to the Minister of Health the Guidelines from the sale of gametes, embryos or any bio- for tissue engineering and cell treatment, togeth- logical material, as well as from promoting any er with the report on the “Regulatory aspects businesses intending to do so, and from dis- associated with genetic treatments: a guidebook seminating information regarding it. The ordi- to producers and users”. nance is still in force and is likely to remain so At present, the Government is working on a pro- until Parliament adopts a satisfactory legislation gramme to promote the development of on the issue. biotechnologies in Italy. 3.4 Genetic tests 3.2 Cloning Regarding genetic tests for diagnosis and pre- WHO Resolution 51.10 stated that “… cloning diction, the National Biosafety and Biotechnolo- for the replication of human individuals is ethical- gy Committee has recently released specific ly unacceptable and contrary to human dignity guidelines which aim to define certain general and integrity”. Genetic interventions on non principles regarding the way health profession- human species may contribute to the improve- als perform and manage the above tests. These ment of human health and well-being, but more principles provide a framework for an appropri- data are required to be able to reach objective ate use of safe and effective tests, guaranteeing conclusions on risks and benefits. they are carried out in laboratories working to In 1997, there was a great surge of alarming high quality standards and with a management news regarding the uncontrolled cloning of sev- structure which provides the user with informed eral animal species. In light of that situation, decision-making autonomy. At the same time the Italian Minister of Health issued an ordi- these structures should supply proper psycho- nance banning the development of any form – logical and social supports, paying attention to be it direct or indirect – of experimentation ethical and confidentiality issues when handling aimed at achieving human or animal cloning. critical data. These guidelines are now in the Since then, this ordinance has been reiterated process of being formally adopted. 166 - Bioethics in human health

4. ORGAN AND TISSUE TRANSPLANTS for children and adolescents, as well as the setting up of a network of facilities and services to Italy has recently passed Law No. 19/1999 on promote and deliver services to children. The time organ and tissue transplants. This law regulates is right to approach childhood and adolescence matters associated with the expression of the from an ever-growing preventive, curative and individual’s will to donate his/her organs and the rehabilitative perspective, including the contribu- organization of the system in charge of oversee- tions which biomedical research can give to it. ing organ removal and transplantation. The Protecting and promoting health in children is an above law follows on from Law No. 578 of 1993 area where it is of the utmost importance to have and Decree No. 582 of 1994 by the Minister of effective integration between health interven- Health, relating to the procedures required to tions and social-welfare services, integration ascertain human death. between maternal and child health services and The new regulations, based on the rule that educational and social-welfare services; that is, everybody is considered a donor unless he/she true integration in keeping with the spirit of refuses to be, have taken stock of the many health solidarity. pressing matters raised by the scientific world, by This is one of the needs clearly stated in the voluntary associations, by patients waiting for Action Plan for Childhood and Adolescence, transplants and by public opinion in general. The passed by the Italian Government in April 1997. end result has been a modernization of the legal In Italy, the network of family counselling centres framework, which should raise Italy out of its cur- is being strengthened, especially by fostering rent unsatisfactory ranking position in Europe in their integration within the network of individ- terms of the total number of organs available; ual-oriented services. plans are underway to reach the standards common to other countries. 6. TERMINALLY-ILL PATIENTS

5. CHILDHOOD: A HIGH-PRIORITY AREA Medicine in the year 2000 is no longer called upon to provide only therapeutic solutions for Italy’s past is dotted with sectoral and episodic diseases and to preserve life, but also to elabo- interventions in the field of childcare, and the rate operational proposals and actions designed focus has been more on resolving urgent prob- to give meaning and quality to the care of lems rather than planning a global development patients with no hope of recovery, but who must strategy for children. Public Administration has be taken care of. not always been able to effectively coordinate its This is the reason why what has been termed activities both at the national and local level, as “palliative care” has come into being and why well as between the central and local administra- the “hospice movement” is now spreading tions. throughout the world. More recently Italy has shown renewed attention Italy is making major investments in terms of pal- to matters regarding children and adolescents, liative care and integrated home care. The Min- placing special emphasis on their living condi- istry of Health recently allocated a substantial tions, needs and natural desires to grow up and part of its funds to build hospice-like facilities. achieve their full potential as adults. These are intended to provide a protected health Several political initiatives have brought about environment for patients, who are physically and substantial progress, promoting improvements in mentally worn out and who are entitled to the juvenile justice system and living conditions respect and dignity in their last days of life CHAPTER X

THE ITALIAN NATIONAL HEALTH SERVICE

CONTENTS

1. MULTISECTORAL RESPONSABILITY FOR HEALTH ...... 168 1.1 Administrative aspects ...... 168 1.2 Legislative aspects ...... 169 2. MISSION ...... 169 3. OVERALL ORGANIZATION ...... 169 3.1 The central level ...... 170 3.2 The regional level ...... 171 3.3 The local level ...... 172 4. FINANCIAL RESOURCES FOR HEALTH ...... 176 4.1 Health expenditure ...... 176 4.2 Health financing ...... 177 5. SERVICES ...... 182 5.1 Community health and hygiene ...... 182 5.2 Primary health care ...... 183 5.3 Specialist treatment ...... 192 5.4 Hospital care ...... 192 5.5 Care and rehabilitation of non self-sufficient persons ...... 204 6. HUMAN RESOURCES ...... 204 7. HEALTH CARE QUALITY ...... 204 7.1 Management of quality ...... 204 7.2 Avoidable deaths ...... 206 7.3 Health care quality assurance ...... 211 7.4 Perception of care quality ...... 212 8. PARTNERSHIPS FOR HEALTH ...... 212 168 - The Italian national health service

1. MULTISECTORAL RESPONSIBILITY FOR key production sectors, both at industrial level HEALTH (e.g. biotechnologies and health and safety at work) and agricultural level (e.g. veterinary 1.1 Administrative aspects public health and food safety), as well as of tourism flows, the import-export of many Compared to many other countries, one pecu- goods as well as the manufacturing and mar- liar characteristic of Italy is the fact that its Min- keting of medicines, medical devices and cos- istry of Health has much wider-ranging admin- metics. Moreover, some environmental health istrative competencies. In fact, the Italian Min- standards (e.g. air and water quality) also fall istry of Health is not only responsible for plan- within the competencies of the Ministry of ning health expenditure and ensuring adequate Health, as does the control of their implemen- health care services, but also for protecting cit- tation on the ground through the structures of izens’ health through the preventive control of the National Health Service.

TARGET 14 - HEALTH21

By the year 2020, all sectors should have recognized and accepted their responsibility for health.

In particular: 14.1 decision-makers in all sectors should take into consideration the benefits to be gained from investing for health in their particular sector and orient policies and actions accordingly; 14.2 Member States should have established mechanisms for health impact assessment and ensured that all sectors become accountable for the effects of their policies and actions on health.

The impact of the above-mentioned arrange- taken properly into account in certain policies, ment regarding the integration of health into several other mechanisms have been set in other policies is strongly enhanced by the verti- place to assess health impact and to ensure that cal coordination mechanisms existing between all sectors become accountable for the effects the Ministry of Health and the local Health Ser- of their policies and actions on health. At gov- vice structures1 which are responsible for the ernmental level, these additional administrative implementation of health policies in Italy. Of all mechanisms include: the various Bodies existing in Italy to ensure the coordination role of the Presidency of the cooperation among the central and regional Council of Ministers for broad horizontal policies Administrations, the Permanent Conference on involving the competencies of several Ministries; the Relationships between Central Government inter-ministerial cooperation for specific policies and the Governments of the 21 Regions and concerning two or more Ministries; this is par- Self-governed Provinces is the most formal ticularly the case of the Ministry of Health with one2. the Ministry of Environment in relation to envi- Although these peculiarities make it simpler in ronmental health issues, with the Ministry of Italy to ensure that health considerations are Social Affairs in relation to the integration of

1 See paragraph 3 for explanation. 2 In this report, this conference is also referred to as “Permanent State/Regions Conference”. The Italian national health service - 169

health and social aspects and with other Min- criteria (see Chapter XIII). The INHS basic princi- istries (e.g. Industry or Agriculture) in relation to ples are: other specific subjects. • Human dignity: according to which every The formal aspects of these administrative individual must be treated with equal digni- coordination mechanisms are also established ty and have equal rights irrespective of within the hierarchy of the legal acts needed for his/her personal characteristics and role in adopting regulations on specific multisectoral society; matters (i.e. Interministerial Decrees, Decrees of • Protection: according to which the health of the President of the Council of Ministers, the individual must be protected before it is Decrees of the President of the Republic or Leg- undermined; islative Decrees). • Need: according to which those in need have a right to health care and available resources 1.2 Legislative aspects must, as a priority, be allocated to the promotion of activities aimed at meeting the primary For policies which need new legislation to be health care needs of the population and public adopted, mechanisms ensuring that the health; impacts on health are adequately taken into • Solidarity towards the most vulnerable: account are built into the Central and which demands resources to be allocated pri- Regional Parliamentary procedures as well as marily to support groups of people, individuals into the modalities of participation by central and certain diseases that are socially, clinically Government in the work of the National Par- and epidemiologically important; liament. • Effectiveness and appropriateness of interventions: to which resources must be channelled for services whose effectiveness is 2. MISSION scientifically grounded and for individuals that can benefit the most from them; The Italian National Health Service (INHS) was • Cost-effectiveness: which stresses that established by Law No. 833 of 23 December when choosing among different supply pat- 1978 with the objective stated under article 32 terns and types of activities, priority should be of the Italian Constitution concerning the safe- given to solutions which offer optimal effec- guarding of the health of each citizen as an tiveness as compared to costs; individual asset and a community interest. It • Equity: which guarantees that no geograph- subsequently underwent significant adjust- ical and economic barriers should prevent any ments and changes with Legislative Decree No. individual form accessing the health care sys- 502 in 1992 and No. 517 in 1993. A reform of tem and that information gaps and behaviour- the INHS, which deals with a number of impor- al differences should be bridged to avoid health tant aspects, has recently been approved by discrimination among individuals and groups of Law No. 419 in 1998 and Legislative Decree No. people; equal access and availability of health 229 in 1999 (see Chapter XV). care must be guaranteed in the light of equal The INHS is made up of people, means and needs. facilities which, as a whole, are committed to preventing, diagnosing and treating diseases and to promoting the health recovery of the 3. OVERALL ORGANIZATION population at large. Ensuring equal access to health care is the main The operations of the INHS require a complex goal of the Italian National Health Service organization which must ensure the proper (INHS) and of its financial and organizational coordination and smooth running of all the 170 - The Italian national health service

components (human resources, facilities and inequalities and into unequal access to health equipment). services. All citizens are entitled to receive health care Abolishing economic barriers which hamper services included in essential levels3 (Art. 50, Act access to health services may not be sufficient No. 450/1997 and Decree Law No. 124/1998): to guarantee access to those who have equal • at no cost at the point of use with respect to: needs and uniform access to the various ser- – instrument and laboratory diagnostics, as well vices throughout the nation must be ensured, as other specialised services provided for in pro- regardless of differences among social groups grammes for early diagnosis and mass preven- (see Chapter XIII). tion, carried out in accordance with the INHP, The Italian National Health Service is structured regional health plans, or promoted or autho- on three main different levels (central, regional rized by formal decisions of Regional and and local). Provincial authorities; – instrument and laboratory diagnostics, as well as 3.1 The central level other specialised care services aimed at protecting public health, which are compulsory by law or set The central Government and the Ministry of as mandatory by local authorities following epi- Health, in particular, determine the INHS targets demic outbreaks, and also medical investigations and the most important measures to be imple- included under employment contracts; mented; they outline the services to which the – general medical and paediatric services cho- entire population is entitled under conditions of sen freely by the user; uniformity, and allocate to the Regions and self- – treatments administered during hospitalisa- governed Provinces the financial resources deriv- tion, including rehabilitation and long-term ing from the taxation funds and appropriated by post-acute inpatient care; Parliament (National Health Fund) (see Chapter – services directly and closely related to elective XIII). Moreover, the Ministry of Health has the hospitalisations, previously delivered by the task of supporting, monitoring and assessing the same facility, in compliance with Art. 1, item furthering of health objectives and serves as a 18, Act No. 662 of 23 December 1996. guide for the uniform implementation of preven- • upon payment of a limited contribution for tion and care throughout the national territory in the remaining services, which are not fully cov- order to ensure equity in access to the INHS. If ered by the INHS, in accordance with legislation necessary, the Ministry may also intervene in in force. The cost-sharing mechanism is meant cases of persistent or serious mismanagement. to make the user aware of the economic bur- In addition to the Cabinet, Legal Office, Press den attached to service provision, but in no way Office, 5 departments and 7 services based in will it hamper access to health care. In compli- the headquarters in Rome (Figure X.1), the Min- ance with the 1998-2000 Financial Planning istry of Health also comprises territorial health Document, social equity goals require that the and territorial veterinary offices (Figure X.2). INHS provides health care uniformly by imple- As far as technical and scientific matters are menting measures and undertaking actions concerned, the INHS is complemented by three aimed at eliminating factors which could turn highly qualified National Organizations, namely social and economic differences into health the “Istituto Superiore di Sanità” (National

3 Essential health care levels stand for services and standards that are necessary (because they satisfy the basic needs of promoting, maintaining and restoring health in the population) and appropriate (both regarding the individual’s specific health requirements and the ways in which services are provided). As such, they should be delivered uniformly throughout the nation and be guaranteed to everybody in full recognition of the differences that characterize the distribution patterns of health care needs and health risks. The Italian national health service - 171

Figure X.1: Ministry of Health of Italy: Organizational Chart.

* Two undersecretaries of State have been appointed.

Source: Ministry of Health of Italy, 1999.

Institute of Health), the “Istituto Superiore per vices in relation to the needs of the popula- la Prevenzione e la Sicurezza del Lavoro” tion; they appoint the managers of both Local (National Institute for Prevention and Safety at Health Unit Agencies4 and Hospital Agencies Work) and the “Agenzia per i Servizi Sanitari and coordinate their actions, supervise the Regionali” (National Agnecy for Regional attainment of results and intervene in cases of Health Care Services) (see Annexes 2, 3 and 4 mismanagement. respectively). Highly-reputed technical and sci- Each Region and self-governed Province allo- entific opinions are provided also by Higher cates to all the Agencies within its territory a Health Council (see Annex 9). part of the National Health Fund transferred by the Ministry of Health according to pre-deter- 3.2 The regional level mined criteria. In the structure of each regional and self-governed provincial government there The 19 Regions and 2 self-governed Provinces is one sector (called “Assessorato” in Italy) plan health care activities and organize ser- which deals with health.

4 In this report, also referred to as “Local Health Agencies”. 172 - The Italian national health service

Figure X.2: Ministry of Health: peripheral health and veterinary offices.

MoH Offices for Airport/Port Health Veterinary Offices for Community Matters

Source: Ministry of Health of Italy, 1999.

3.3 The local level university-managed hospitals) and private structures (nursing homes and laboratories The structure of health care at local level under contract to the INHS) which work under includes community health care at home and at their supervision. In 1998 there were in Italy work, district health care and hospital care (Fig- also 98 hospitals which have the same level of ure X.3). administrative responsibility as Local Health In 1998, there were 196 Local Health Agencies Agencies. These hospitals are qualified as “Hos- in Italy providing health care services to the pital Agencies” (Aziende Ospedaliere) due to population either directly, through their own the fact that they have super-regional functions facilities, or paying for the services provided by or act also as University centres. Hospitals pro- independent public structures (hospitals and vide inpatient care for one or several specializa- The Italian national health service - 173

tions with diagnostic facilities and possibly also have full autonomy in organizational, adminis- outpatient care. Hospitals may be public of pri- trative, financial, accounting, managerial and vate and the latter may choose whether or not technical terms, and must operate within the to enter into contracts with the National Health limits of the yearly health budget determined Service. Public hospitals and private hospitals by the Regional Government. The managing under contract are financed mainly on the basis director is responsible for seeing that the limits of the services provided (“diagnosis-related of the budget allocated are complied with. groups” system). The organizational structure of Local Health Thus, it is up to the individual to choose from Agencies is harmonized at a national level even which health facility he/she wishes to receive though significant structural differences exist treatment. The Local Health Agencies are also among different Agencies, as highlighted in a responsible for the daily management of the monitoring study of 217 Agencies carried out health services and are in charge of providing by the Ministry of Health in 1997 (Table X.1A). primary care, including contracts with general This situation depends both on the flexibility of practitioners (GPs), provision of occupational the system, which largely allows for territorial health services, health education, disease pre- peculiarities and autonomy, and on the fact vention, pharmacies, family planning, child that the harmonization of Local Health Agency health and information services. structures with criteria set in national guidelines The “Local Health Agencies”, are the mainstay is an on-going process undertaken by Regions of the INHS. These “Agencies”, known as according to their own time frames. The num- “Aziende Sanitarie Locali”, are run by man- ber of Local Health Agencies is decided by each agers appointed by the President of the Gov- Region; in fact, the total number of Local ernment of the Region or Self-governed Health Agencies decreased from 227 in 1997 to Province to which the Agency belongs. They 196 in 1998 (Table X.1B).

Figure X.3: Health Care Structure*.

1. Community Health Care at home and at work

• Prevention of communicable diseases • Protection from environmental pollution-related risks • Protection from risks at home and at work • Veterinary Public Health • Food Safety

2. District Health Care

• Primary Health Care • Pharmaceutical Care • Outpatient specialist care • Community-based and semi-residential care • Residential health care

3. Hospital Care

• Acute care (emergency, routine and day-hospital care) • Post-acute health care (hospital-based and long-term rehabilitation)

*By supply area. Source: Ministry of Health of Italy, 1999. 174 - The Italian national health service health national Italian The - 174

Table X.1A: Structures and some special services of Local Health Agencies in Italy in 1997.

TRANSPORTATION ACTIVE UNIFIED MENTAL PREVENTION SERVICE MATERNAL ANDINTEGRATED REGION DISTRICTS RESERVATION HEALTH DEPARTMENT HAEMODIALYSIS CHILD HEALTH HOME CARE LOCAL HEALTH CENTRE DEPARTMENT CENTRE DEPARTMENT SERVICE AGENCIES

MONITORED EXISTING IN 1997 IN 1997 PIEMONTE 64 17 17 16 11 15 27 22 22 VALLE D’AOSTA 111 LOMBARDIA 293 36 26 18 12 17 41 44 44 PROV. AUTON. BOLZANO 11 1 2 2 1 2 4 4 4 PROV. AUTON. TRENTO 11 1 1 1 1 1 1 VENETO 85 16 17 20 10 7 18 21 21 FRIULI VENEZIA GIULIA 19 3 6 6 2 1 6 6 6 LIGURIA 22 4 3 2 3 2 5 5 5 EMILIA ROMAGNA 48 13 12 13 8 10 8 13 13 TOSCANA 160 10 12 12 7 7 10 12 12 UMBRIA 65 3 3 3 1 1 2 5 5 MARCHE 65 6 8 6 8 5 9 13 13 LAZIO 47 5 11 6 5 8 10 11 12 ABRUZZO 23 3 4 4 1 3 1 4 6 MOLISE 5 2 1 1 4 4 CAMPANIA 90 4 9 101721113 PUGLIA 61 11 12 114531212 BASILICATA 25 1 4 1 1 1 2 5 5 CALABRIA 19 1 4 3 1 3 2 11 11 SICILIA 26 5 1 1 3 2 6 9 SARDEGNA 11 4 3 1 1 6 8

ITALY 1 150 137 160 139 78 98 149 217 227

Source: SIS, Ministry of Health of Italy, Dipartimento Programmazione, Flussi informativi delle ASL e delle Aziende Ospedaliere, 1999. The Italian national health service - 175

Table X.1B: Number of Local Health Unit Agencies and Hospital Agencies in Italy by Region in 1998.

REGION LOCAL HEALTH AGENCIES HOSPITAL AGENCIES PIEMONTE 22 7 VALLE D’AOSTA 1 LOMBARDIA 14 27 PROV. AUT. BOLZANO 4 PROV. AUT. TRENTO 1 VENETO 21 2 FRIULI VENEZIA GIULIA 6 3 LIGURIA 5 3 EMILIA ROMAGNA 13 5 TOSCANA 12 4 UMBRIA 4 2 MARCHE 13 4 LAZIO 12 3 ABRUZZO 6 MOLISE 4 CAMPANIA 13 8 PUGLIA 12 6 BASILICATA 5 2 CALABRIA 11 4 SICILIA 9 17 SARDEGNA 8 1

ITALY 196 98

Source: Ministry of Health of Italy, 1999.

In addition to managing hospitals, Local Health these services. Even when resources and pro- Agencies manage the districts that represent duction are equal, the Districts’ organizational the centres where healthcare is dealt with in a profiles may differ from one District to another, global and unitary way. depending on local strategies. The District is an operational structure of the Districts are responsible for ensuring that peo- Local Health Agency. Its autonomy is ensured in ple have access to basic health services with accordance with the programmes approved by clear methods and defined timing through a the same Agency, taking into account the area- network of on-line systems that link all health related service plans as established with local service providers. Finding health services, both governments. outpatient and hospital based, shall be guaran- The size of the District is set according to the teed by Districts to all area residents. guidelines provided for by Art. 2 of Legislative Within each District, General Practitioners and Decree No. 502/92 and its successive amend- paediatricians chosen by a resident are the ments. The characteristics of both the area, direct reference points for people and families. population distribution and its productive activ- They are in charge of promoting and fostering ities are also taken into account. The organiza- health and for evaluating the real needs of the tional structures will depend on the number of people so as to orient and ensure access to the health care services provided and the nature of National Health Service. 176 - The Italian national health service

Districts benefit from resources allocated by the resources needed to fund some of the new Local Health Agencies which depend on the investments that will be required to adopt more volume of activity planned in each District. In effective (but often expensive) new technologies order to optimize District services, regional gov- and to provide care for the increasing numbers ernments must specify in their plans the home of elderly people. care, intermediate and residential care services International comparisons of health expendi- to be delivered and the different financing tures are extremely difficult because the defini- sources. tions underlying health statistics, as well as Professional, economic and other types of accounting practices, vary from one country to resources in a District are managed by the exec- another. Moreover, health expenditure depends utive responsible for that District. General Prac- largely on the economic status of a country and titioners, together with other health and social varies significantly within the WHO European sector operators, play a very relevant role and Region. The level of financial resources required are integrated into the District’s organization. to operate a health service is impossible to specify in absolute terms and it is not easy to correlate this level of funding with each country’s 4. FINANCIAL RESOURCES FOR HEALTH5 needs in the health sector. Certainly, the amount should be affordable by the country and enough Adequate financial resources and efficient run- to meet the needs of both health promotion and ning of health services are essential for the pro- the provision of effective and high quality care. vision of health care. Prudent use of available These objectives are simply stated but are much resources requires that steps be taken to focus more difficult to reconcile in practice. attention on the quality of care and on planning and managing the entire health sector, evaluat- 4.1 Health expenditure ing the relative values of health promotion, disease prevention, diagnosis/treatment, rehabilita- Within EU countries, total health care expendi- tion and care. A special problem comes from ture6 as a percentage of GDP in 1997 ranged

TARGET 17 - HEALTH21

By the year 2010, Member States should have sustainable financing and resource allocation mechanisms for health care systems based on the principles of equal access, cost-effectiveness, solidarity and optimum quality.

In particular: 17.1 spending on health services should be adequate, while corresponding to the health needs of the population; 17.2 resources should be allocated between health promotion and protection, treatment and care, taking account of health impact, cost-effectiveness and the available scientific evidence; 17.3 funding systems for health care guarantee universal coverage, solidarity and sustainability.

5 In this text, 1 billion corresponds to 1 000 million. In addition, 1 Euro corresponds to 1 936.27 ITL. 6 According to the OECD Health Data 98, OECD, Paris, 1998, the total (or national) expenditure on health is based on the following identity and functional boundaries of medical care: total current expenditure on health and investment into medical facilities (i.e. recurrent plus capital costs). The Italian national health service - 177

from 6.7% in the United Kingdom to 10.4% in The allotment of the overall “public” expendi- Germany. Italy spent 7.6% of its GDP on ture in 1997 to different budgetary items is health, a slightly lower value than the EU aver- shown in Table X.3. age of 7.9% (Figure X.4) (OECD, 1998). Public health expenditure for inpatient care8 as Public expenditure on health7 amounted to a percentage of the total health care expendi- about 109 000 billion ITL or 56 million Euros, ture in 1995 varies largely with the country. In corresponding to 5.58% of the GDP in 1997. In Italy, 40.2% of the total health expenditure was the same year, per capita public health expen- allocated to inpatient care. The average for the diture was a total of 1 890 000 ITL. The trend EU countries was 37.2% in the same year (Fig- during the last few years (Figure X.5) shows the ure X.7). decrease in the percentage of GDP spent on health from 1993 to 1995 and the increase 4.2 Health financing occurring from 1995 to 1997. The legislation adopted in Italy in 1992 consid- 4.2.1 Current expenditures erably modified the financial structure of the public health care system; in particular, as a Public health expenditure is covered by result of strong decentralisation measures, resources made available by citizens through which delegated certain decision-making activ- general taxation. The contribution of the ities to regional authorities, public expenditure national government comes from the taxation on health varied significantly among the Italian funds appropriated by Parliament each year Regions (Table X.2). Figure X.6 shows that there with the national budget or by the Region. is a steadily increasing South-North trend of Additional funds come from the so-called public health expenditure per capita in Italy. In “direct” contributions associated with co-pay- fact, there is no Region spending more than ment by users of some service costs, such as 1 890 000 ITL per person on average in the those of medicines, outpatient treatments, as South and the Islands, whereas all the Regions well as diagnostic tests. The overall yearly and self-governed provinces spending above amount needed for health financing is estab- 1 890 000 ITL are located in Central and North- lished on the basis of the “capitation” or “per ern Italy. Those spending above 2 200 000 ITL capita quota” system (known as “quota capi- are in Northern Italy. taria di finanziamento”) representing the The large variation occurring among different national sum per person needed to cover the Regions with respect to recurrent expenditure essential health care levels guaranteed by the on hospital care can be partly explained by the Italian National Health Service. As this value existing differences both in terms of availability was equal to 1 736 286 ITL in 1997, the overall of health services (supply) and demand for health national budget in this year correspond- health care among Italian Regions. The people ed to 99 546 billion ITL. However, the total living in a certain Region, in fact may, and often health expenditure in 1997 was 108 853 billion do, choose health facilities located in an anoth- ITL. This corresponds to a deficit of 9 306 billion er Region. ITL, without including 678 billion ITL which the

7 According to the OECD Health Data 98, OECD, Paris, 1998, publicly funded care in institutions, whether publicly or privately owned, and where public refers to central and local authorities, health boards and social insurance institutions. Public capital formation on health includes publicly-financed investment in health facilities plus capital transfers to the private sector for hospital construction and equipment and subsidies from government to health care service providers. 8 Inpatient care includes: Acute hospital care, Psychiatric hospital, Nursing homes and others long-term care. All types of private and public hospital are taken into account (general hospitals, special hospitals, extended care, mental hospitals, tuberculosis hospitals. 178 - The Italian national health service

Figure X.4: Total health expenditure as a percentage of the GDP in EU countries - 1997.

Source: OECD, 1998.

Figure X.5: Public expenditure on health as a percentage of GDP in Italy - 1993-1997.

Source: Ministry of Health of Italy, 1999c. The Italian national health service - 179 ove 74 years. , 1999. IN ITL IN EURO AVERAGE (ITL X 1 000) PER INHABITANT IN EURO INHABITANT FROM NATIONAL (ISTAT 1997)(ISTAT EXPENDITURE EXPENDITURE EXPENDITURE EXPENDITURE PER DIFFERENCE POPULATION TOTALAVERAGE TOTAL AVERAGE PERCENT REGION Table X.2: Total current health expenditure in Italy. Year 1997. Year in Italy. health expenditure current X.2: Total Table PIEMONTE D’AOSTAVALLE LOMBARDIAPROV AUT BOLZANOPROV AUT TRENTOVENETOFRIULI VENEZIA GIULIA LIGURIAEMILIA ROMAGNA 119 224 454 330 4 294 127TOSCANA 8 958 670 464 398UMBRIA 1 186 244MARCHE 1 075 052 108LAZIO 7 802 423 000 272 183 742 17 519 046 914ABRUZZO 3 937 924 2 452 123 226MOLISE 4 452 793 980 765 380CAMPANIA 2 366 000 1 817 000 2 283 000PUGLIA 1 650 724 1 956 000BASILICATA 8 394 707 000 2 067 000 3 524 670 2 112 000 8 876 751 000CALABRIA 4 029 615 188SICILIA 555 218 078 829 915 3 508 882 425 1 447 606 9 047 832 644 140 571 171SARDEGNA 1 266 415 958 2 132 000 6 970 981 000 1 994 000ITALY 1 273 665 506 523 047 5 217 168 1 222(a) 14.7% of which between 0 and 14 years; 43 4% 15 44; 24 8% 45 64; 10 1% 65 74 70% ab 938 5 785 352 1 010 2 126 000 1 179 1 656 847 040 3 166 235 777 330 696 1 068 4 335 504 346 1 978 000 4 584 459 295 10 173 555 675 1 091 2 328 339 399 4 087 697 607 859 10 450 080 793 2 074 157 1 812 186 536 1 996 000 2 187 000 1 101 25 –4 1 030 3 600 211 230 1 662 955 21 592 845 221 3 1 950 000 5 100 803 1 828 000 7 007 710 412 9 1 806 000 989 359 815 12 1 098 3 586 162 309 57 460 977(a) 1 635 224 311 855 690 085 1 022 2 982 188 727 1 793 000 5 254 203 017 1 202 486 946 7 792 638 955 13 1 714 000 108 578 879 918 5 397 016 322 6 1 628 000 1 729 000 1 129 1 031 12 1 793 000 1 007 1 528 000 306 179 004 3 619 180 389 944 1 890 000 5 1 852 098 266 933 510 961 702 16 1 540 171 942 4 024 562 150 6 56 076 311 627 926 885 3 893 –3 841 –4 926 789 976 –5 –9 –9 –14 –5 –19 Source: SIS, Ministry of Health of Italy, Dipartimento Programmazione, Flussi informativi delle ASL e Aziende Ospedaliere Source: SIS, Ministry of Health Italy, 180 - The Italian national health service

Figure X.6: Health care expenditure per inhabitants in Italy, by Region - 1997.

Source: Ministry of Health of Italy, 1999c.

Figure X.7: Public expenditure for inpatient care as a percentage of the total health care expenditure in the EU countries. Time trend.

Source: OECD, 1998. Table X.3: Health expenditure in Italy subdivided into aggregates: January – December 1997.

ECONOMIC AGGREGATES (IN EURO)

SPECIALIZED SPECIALIZED TREATMENTS TREATMENTS REGION PERSONNEL GOODS AND GENERAL MEDICINES HOSPITALS (INTRA (EXTRA OTHER HEALTH PLANNED INTEREST TOTAL CURRENT SERVICES PRACTITIONERS MOENIA) MOENIA) CARE SERVICES OBJECTIVES PAID EXPENDITURES

PIEMONTE* 1 853 514 747 917 791 940 245 569 058 431 603 031 180 460 886 35 747 597 23 625 837 327 214 696 12 887 665 1 199 729 4 029 615 186 VALLE D’AOSTA 71 831 198 36 871 026 7 959 204 10 845 595 301 929 1 399 170 799 595 7 107 947 3 329 261 126 247 140 571 172 LOMBARDIA 3 510 375 667 1 698 398 432 489 907 214 955 714 454 1 427 177 798 64 712 310 143 222 473 724 356 770 26 092 055 7 875 472 9 047 832 645 PROV AUT BOLZANO 290 146 901 133 491 241 27 351 674 29 633 325 33 461 877 1 458 991 2 139 689 31 963 982 5 088 522 481 876 555 218 078 PROV AUT TRENTO 248 676 607 92 400 296 28 363 813 38 593 467 36 367 944 4 045 114 1 884 551 52 828 075 3 224 687 138 493 506 523 047 VENETO* 2 082 307 220 1 070 895 071 255 036 229 400 694 118 267 803 560 35 028 173 61 600 913 406 937 049 – 4 156 962 4 584 459 295 FRIULI V. GIULIA 594 877 076 248 032 126 64 384 095 108 984 357 149 232 530 7 533 670 5 580 956 67 892 315 17 976 169 1 922 665 1 266 415 959 LIGURIA 778 294 943 348 800 873 87 456 732 210 591 736 229 342 886 20 948 190 11 155 852 107 133 803 16 955 639 1 505 882 1 812 186 536 EMILIA ROMAGNA* 1 938 779 199 1 030 847 971 238 021 557 393 448 228 312 692 961 42 696 525 23 109 897 303 649 284 41 574 780 10 683 944 4 335 504 346 TOSCANA* 1 750 110 264 756 410 521 227 815 336 379 931 518 116 618 034 39 661 824 26 431 231 275 243 122 24 232 674 3 756 707 3 600 211 231 UMBRIA 434 992 133 190 816 531 48 971 308 100 419 738 21 610 556 8 491 927 3 112 044 43 340 273 3 209 685 725 890 855 690 085 MARCHE 692 479 304 359 668 780 88 408 320 171 560 923 197 802 432 17 380 139 14 691 941 67 098 324 23 127 091 3 007 058 1 635 224 312 LAZIO 1 909 946 934 688 725 975 319 594 817 649 092 037 1 184 125 251 100 331 770 113 249 381 257 105 241 19 468 473 12 563 136 5 254 203 015 ABRUZZO 547 178 835 211 529 952 79 286 721 145 442 307 113 649 803 10 918 504 8 286 919 71 123 477 14 774 372 296 055 1 202 486 946 MOLISE 152 634 545 51 942 118 22 532 090 34 189 312 16 127 994 4 347 367 2 766 045 17 255 389 3 915 529 468 618 306 179 007 CAMPANIA 2 196 871 735 642 736 986 392 479 551 786 735 702 691 837 851 88 614 662 179 879 094 389 613 128 24 901 357 3 346 255 5 397 016 321 PUGLIA 1 485 480 550 532 969 539 238 921 859 473 984 303 585 419 017 47 314 700 49 595 973 170 907 292 33 743 692 843 463 3 619 180 388 BASILICATA 224 169 921 102 296 890 38 432 365 68 039 798 5 322 098 2 776 768 4 330 238 61 983 263 3 495 536 114 826 510 961 703 CALABRIA 902 863 134 234 511 647 155 297 311 246 144 111 158 080 062 32 563 544 30 448 573 76 884 437 14 913 946 391 501 1 852 098 266 SICILIA 1 843 702 862 518 844 148 315 660 984 501 152 741 410 588 730 76 978 543 103 185 213 231 527 118 22 110 217 811 594 4 024 562 150 SARDEGNA 778 877 785 272 865 427 113 060 012 161 957 859 81 232 779 16 082 331 16 734 514 90 448 295 8 757 412 155 529 1 540 171 943

ITALY 24 288 111 560 10 140 847 490 3 484 510 250 6 298 758 660 6 219 256 978 659 031 819 825 830 929 3 781 613 280 323 778 762 54 571 902 56 076 311 631

NOTE: TOTAL CURRENT EXPENDITURE DOES NOT INCLUDE HEALTH CO-PAYMENTS AND TRANSFERS TO THE NATIONAL HEALTH FUND. 181 - service health national italian The (*) Regions for which total health care expenditure is calculated on the basis of public accounting at regional level. Source: SIS, Ministry of Health of Italy, Dipartimento Programmazione, Flussi informativi delle ASL e delle Aziende Ospedaliere, 1999. 182 - The Italian national health service

national Government used to cover the costs of gramme to improve health care structures (also special health institutions (Ministry of Health of by refurbishing obsolete departments for infec- Italy, 1999c, in press). tious diseases), increasing staff numbers, According to present regulations, deficits must upgrading diagnostic laboratory activities and be levelled off by equivalent additional improving home care services. resources from: • the national government, if the deficit does not depend on regional decisions (e.g. greater 5. SERVICES expenditure caused by national regulations or higher than the expected inflation rate); The services provided by the INHS include: • the Regions, if the deficit was caused by • Community health and hygiene; regional decisions; to this end, the Regions may • Primary health care; increase each individual’s participation in meet- • Specialist treatment; ing costs or increase health contributions and • Hospital care; regional taxes. • Care and rehabilitation of non self-sufficient persons. 4.2.2 Investment expenditure 5.1 Community health and hygiene There are several ad-hoc financing channels for investment health expenditure. Activities related to community health and • Relevant quota of the National Health Fund. hygiene include: In 1997, this quota was equal to 400 billion ITL, • Vaccinations: e.g. compulsory vaccinations of which 385 billion were transferred to (polio, tetanus, diphtheria, hepatitis B) and Regions. optional – though strongly recommended – • Resources allocated concerning the special vaccinations (rubella, measles, parotitis and programme for health investments. This pro- whooping cough); gramme intends to make provision for 140 000 • Control of living and working premises beds in so-called health care residences (RSA) and of environment-related health risks: for both the elderly and the disabled; about e.g. inspection and sanitary control of schools 24 000 beds have been made available so far. and occupational health and safety; On average, there are 2.5 beds per 1 000 peo- • Livestock control: e.g. inspection and con- ple aged over 65 in Italy; the actual availability trol of farms and of animal trades for the pre- of these beds is much higher in Veneto (7.2 vention of zoonoses and supervision of animal beds/1 000) and Piemonte (4.1 beds/1 000), health protection; and much lower in Sicilia (0.4 beds/1 000) and • Control of food and beverages: inspection Lazio (0.3 beds/1 000). and sanitary control of foodstuff processing These financial resources are also being used operations from production to sale, as well as for structural investments for the IRCCSs, ISS, the handling of food and beverages, including university-managed hospitals and IZSs (see dietary products and baby food. Chapter XI). In the first phase of this pro- These activities are carried out by the 139 gramme, the IRCCSs received 209.7 billion ITL, Departments of Prevention (health and hygiene) ISS 16.1 billion ITL, university-managed hospi- which are currently part of the Local Health tals 113.8 billion ITL and IZSs 79 billion ITL. Agencies in Italy. Environmental sampling and • Resources appropriated concerning urgent laboratory activities are carried out mainly by the interventions for preventing and controlling Regional Agencies for the Environment, which AIDS. This Law authorised a budget of up to are in the process of being set up based on a re- 2 100 billion ITL for a comprehensive pro- structuring of the former 105 Presidi Multizon- The Italian national health service - 183

ali di Prevenzione (Multi-areas Hygiene and Pre- 5.2 Primary health care vention Laboratories), and by the 10 Istituti Zooprofilattici Sperimentali and their numerous In Italy, primary health care (“Assistenza sani- territorial stations (Experimental Zooprophylac- taria di base”) includes diagnosis, treatment tic Institutes) (Figure X.8). and first level rehabilitation together with pre- It should also be mentioned the Nucleo Anti- vention, health promotion and education activ- sofisticazione e Sanità of the Carabinieri that is ities, and, in particular family doctors and pae- a specialized military body in charge of enforc- diatricians, on-call services, pharmacies and ing health and safety regulations and is answer- home carers. able to the Minister of Health (Figure X.9).

Figure X.8: Geographical distribution of Experimental Zooprophylactic Institutes in Italy.*

Source: Ministry of Health of Italy, 1999. 184 - The Italian national health service

Figure X.9: Geographical distribution of the Carabinieri’s Nucleo Antisofisticazione.

Commands against sophistication Groups against sophistication

Units against sophistication

Northern Italy

Central Italy

Southern Italy

Source: Ministry of Health of Italy, 1999. The Italian national health service - 185

TARGET 15 – HEALTH21

By the year 2010, people in the Regions should have much better access to family and community-oriented primary health care, supported by a flexible and responsive hospital system.

In particular: 15.1 at least 90% of countries should have comprehensive primary health care services, ensuring continuity of care through efficient and cost-effective systems of referral to, and feedback from, secondary and tertiary hospital services; 15.2 at least 90% of countries should have family health physicians and nurses working at the core of this integrated primary health care service, using multiprofessional teams from the health, social and other sectors and involving local communities; 15.3 at least 90% of countries should have a health service that ensures individuals’ participation and recognizes and supports people as producers of health care.

General practitioners and primary health reported for the EU but lower than the ratio care nurses; on-call services. observed in some Northern European countries, such as Ireland, Sweden or the UK. In Italy, primary health care is mainly provided Children under 12 years are looked after by by general practitioners (GPs) included in an ad paediatricians. They have the same contracts as hoc list (Figure X.10). The main activities of GPs GPs but are limited to a maximum list size of include providing medical care, prescribing 1 000 (Figure X.11). There are important geo- drugs, ordering diagnostic tests and hospitaliz- graphical variations in the size of GP lists and ing patients. Patients are registered with a GP, the availability of their services, especially who acts as a gatekeeper to specialist services. where paediatricians are concerned, and some The relationship between patient and GP can Regions have smaller physician/population be terminated by either party at any time if it is ratios. not considered satisfactory. The services of GPs A Physician-on-call service (Guardia Medica), are free at the point of use. comprising some 18 000 doctors, provides out- GPs have contracts with the INHS managed by of-hours medical care and services (Table X.4). the competent Region, and are paid on a capi- Doctors working in the Guardia Medica are not tation basis, depending on the number of allowed to take extra contracts, either full or patients enrolled in their lists up to a maximum part-time. of 1 500 per GP. GPs usually work alone, In case of need or emergency, patients can go although they may share their office with one directly to the hospital emergency departments. or more colleagues (so-called “group prac- Patients who turn to hospital emergency tice”). Patients are registered with the doctor departments may have to pay a small contribu- and not the practice. GPs are responsible for tion (known in Italy as a “ticket”). organizing the practice and hiring the necessary Public health nurses have the specific function staff (e.g. nurses and secretaries) who are not of safeguarding the health of individuals and under contract to the INHS. the community through preventive and health In comparison with other countries, the education activities. They try to establish direct GP/population ratio is close to the average relationships with people in their daily life and 186 - The Italian national health service

Table X.4: On-call service in Italy in 1997.

NUMBER NUMBER TOTAL REGION OF ON-CALL OF ON-DUTY NUMBER STATIONS DOCTORS OF HOURS PIEMONTE 134 761 909 676 VALLE D’AOSTA 16 54 73 996 LOMBARDIA 234 1 353 1 700 629 PROV. AUT. BOLZANO 7 42 39 170 PROV. AUT. TRENTO 34 161 205 511 VENETO 117 726 946 402 FRIULI VENEZIA GIULIA 44 169 298 760 LIGURIA 54 224 292 238 EMILIA ROMAGNA 151 741 1 031 549 TOSCANA 185 780 1 112 452 UMBRIA 47 253 367 847 MARCHE 95 399 573 535 LAZIO 116 677 810 592 ABRUZZO 88 400 423 211 MOLISE 62 257 322 880 CAMPANIA 260 2 211 2 788 690 PUGLIA 230 936 1 182 195 BASILICATA 145 296 384 086 CALABRIA 404 1 754 2 054 966 SICILIA 444 2 252 2 609 874 SARDEGNA 169 929 972 417 ITALY 3 036 15 375 19 100 676

Source: SIS, Ministry of Health of Italy, Dipartimento Programmazione, Flussi informativi delle ASL e delle Aziende Ospedaliere, 1999

work, families and the community, using such be privately owned (and have a convention with methods such as interviews, home visits and the relevant Local Health Agency) or belong to a epidemiological surveys. Public health nurses municipality or a hospital, in which case the phar- organize and participate in health promotion macists are paid a salary. In general, hospital programmes, as well as organize and coordinate pharmacies are not accessible to the public. In preventive facilities and services, e.g. family/pae- Italy, there are 16 250 private pharmacies and diatric consultation and immunization centres, 1 129 owned by municipalities. Essential medi- the prevention of infectious diseases, school cines are free at the pharmacy if they belong to health, preventive medicine and occupational List A (see Chapter XI) or available at 50% of the health services. They carry out projects and price if they belong to List B (Table X.5). studies on organizational models for providing Most drugs prescribed under the INHS have a services which are tailored to individual needs. prescription charge, which has increased in recent years (known in Italy as a “ticket”); Pharmacies however, exemptions are made on the basis of income, particular medical conditions or special Pharmacies have the monopoly of drug sales but status (e.g. disabled persons). Both per capita are subject to numerous clauses. A pharmacy can prescriptions and expenditure have been The Italian national health service - 187

Figure X. 10: Number of registered patients per general practitioner in Italy - 1997.

less than 1.000

between 1.000 and 1.086

between 1.086 and 1.200 more than 1.200

National average: 1.086 patients per General Practitioner

Source: SIS, Ministry of Health of Italy, Dipartimento Programmazione, Flussi informativi delle ASL e delle Aziende Ospeadliere, 1999. decreasing in Italy since 1993, when the present Home care regulatory system was adopted, although some recovery has in fact occurred in recent years (Fig- The extent of home care provided in Italy in ure X.12). 1997 is shown in Table X.6. 188 - The Italian national health service

Figure X.11: Number of registered patients per paediatrician in Italy - 1997.

less than 640 between 640 and 685

between 685 and 740 more than 740 National average: 685 patients per Peadiatrician

Source: SIS Ministry of Health of Italy. Dipartimento Programmazione, Flussi informativi delle ASL e delle Aziende Ospedaliere, 1999.

Home care implies a radical change in tradi- There are several ways in which districts can tional health care approaches: the focus shifts provide patients with home care services. Home on patients relying on health care providing care, and in particular integrated home care, facilities, as well as hospitals, to services that represents a unique opportunity to ensure are tailored to meet the needs of patients in health care flexibility and effectiveness. Home their home environment. care becomes integrated (IHC) when different The Italian national health service - 189 OF ITL COST PER FOR INTEGRATIVE PRESCRIPTION CARE , 1999. OF ITL PRESCRIPTIONS AVERAGE COST OF PRESCRIPTIONS NUMBER THOUSAND EURO ITL EURO THOUSAND EURO REGION Table X.5: Pharmaceutical assistance indicators with the Italian National Health System - 1997. Table PIEMONTE D’AOSTAVALLE LOMBARDIA BOLZANO AUT. PROV. TRENTO AUT. PROV. VENETO 1 526 715 19 366 649 514 106FRIULI VENEZIA GIULIA 1 779 749 38 941 793LIGURIAEMILIA ROMAGNA 5 409 694 65 625 166 883 773 656TOSCANA 20 907 048 1 915 380 275UMBRIA 84 911 433 19 600 175MARCHE 230 463 485 19 845 907LAZIO 456 431 002ABRUZZO 33 892 570 989 211 357 9 353 679 731 241 373MOLISE 10 797 589 804 045 601 19 810 668 43 853 095CAMPANIA 119 024 457 45 600PUGLIA 43 000 49 200 40 700 4 913 421 456 247 257BASILICATA 8 418 462 47 700 808 430 107CALABRIA 42 600 377 654 652 23.57 415 254 898 22.20SICILIA 24 823 296 25.40 5 505 159 21.00 201 411 311SARDEGNA 32 159 790 24.64 332 068 378 37 300 1 568 486 22.00 235 632 044 65 301 486 40 500ITALY 1 094 284 568 142 463 381 417 519 306 5 832 324 236 880 268 3 166 968 20 823 617 1 493 869 599 Dipartimento Programmazione, Flussi informativi delle ASL e Aziende Ospedaliere Source: SIS, Ministry of Health Italy, 598 831 11 320 915 19.27 13 085 213 48 800 104 020 261 20.92 70 061 540 33 725 403 40 800 171 499 005 75 576 196 911 317 953 130 186 539 7 375 926 29 077 781 565 150 815 3 012 144 17 298 589 25.19 122 338 449 515 848 652 41 000 771 519 261 21 900 252 39 400 6 757 949 21.08 309 270 285 302 596 1 242 692 442 44 100 284 071 606 36 183 766 43 000 21.17 46 500 470 656 444 12 513 718 257 8 933 976 20.37 11 310 536 67 235 736 26 150 776 319 653 266 413 595 22.77 44 700 22.22 19 440 103 23.99 641 797 085 43 800 41 100 146 710 741 45 600 13 505 749 104 707 163 6 462 796 128 819 026 23.07 165 087 42 700 53 790 655 1 084 862 22.60 38 500 10 039 975 21.23 23.53 43 900 54 076 737 22.07 18 720 261 554 732 422 992 19.89 27 780 555 7 767 862 71 932 072 22.65 560 284 15 197 424 595 552 014 8 587 349 9 668 208 37 149 815 4 011 766 286 495 7 848 815 307 576 947 4 434 996 190 - The Italian national health service

Figure X.12: Number of prescriptions and average net expenditure for medicines per capita in Italy. Time trend. Net Expenditure perNet Expenditure capita (ITL)

Source: Ministry of Health of Italy, 1999.

health and social professionals cooperate in vative non-hospital oriented policy which aims order to implement projects tailored to a to pay closer attention to the population and its patient’s various needs. living standards (see Chapter XIII). Planning IHC implies integration among the dif- The IHNP has planned to allot 3% of the Ital- ferent health care modules, as well as the ian Health National Fund for each of the three enhancement of nursing skills and the collabo- years (1998-2000) on the basis of regional ration of patients’ families, bearing in mind that programmes developed to implement the pri- close cooperation between hospitals and dis- orities agreed upon at national level, including tricts can also enable non-self-sufficient people starting up and enhancing integrated and to be treated in their homes. domicialiry assistance. These programmes Integrated home care must rely on the system- must comply with the following criteria and atic planning of each district’s health service parameters: providers entailing a multidimensional assess- – they must be inter-regional; ment; the holistic aspect of the treatment plan – they must be pluriannual; and its intensiveness; the therapeutic continuity – it must be possible to assess and monitor their of the services; collaboration between health medium–and long–term objectives. and social professionals; the cost-assessment of Furthermore, these programmes must comply the actions to be undertaken; the collaboration with or be consisten with the following priori- of the patients’ families and the evaluation of ties: the outcomes. – reducing social and territorial inequalities in Starting up and developing integrated home health; care schemes is one of the priorities set forth by – adopting truly effective prevention pro- the IHNP 1998-2000. This stems from an inno- grammes; The Italian national health service - 191 00 11 01 LOCAL LOCAL HEALTH HEALTH AGENCIES , 1999. WAITING LISTWAITING MONITORED HOME CARE (%) THERAPISTS TOTAL ELDERLY PHYSIO- NURSES OTHERS TOTAL REGION ASSISTED PATIENTS ON PATIENTS HOURS OF CARE BY ASSISTED PATIENT AGENCIES OFFERING Table X.6: Integrated home care in Italy - 1997. X.6: Integrated home care Table PIEMONTE D’AOSTAVALLE LOMBARDIA AUTON. BOLZANOPROV. AUTON. TRENTO PROV. 104 1 060 29 253 73 409 96.2 94.2 80.5 78.2 871 16 3 3 1 Dipartimento Programmazione, Flussi informativi delle ASL e Aziende Ospedaliere Source: SIS, Ministry of Health Italy, 6 11 12 7 1 2 22 14 16 10 4 41 1 20 41 4 21 1 VENETOFRIULI VENEZIA GIULIALIGURIAEMILIA ROMAGNATOSCANAUMBRIA 11 968MARCHELAZIOABRUZZO 87.0 MOLISE 12 181 15 107CAMPANIAPUGLIA 88.4 BASILICATA 4 558 90.0 CALABRIA 7 129SICILIA 89.6 SARDEGNA 9 432 13 480 61 25 84.8 ITALY 2 19 766 88.9 603 84.8 0 191 38 1 80.6 12 412 64 376 100.0 2 7 1 319 670 13 7 1 568 100.0 104 9 0 79.0 64 312 3 19 8 7.6 25 100.0 200 976 5 1 47 13 97.1 15 3 14 5 82.4 16 1 11 12 15 14 5 28 4 14 13 3 176 12 6 1 28 2 1 1 8 16 24 13 3 0 19 6 5 19 4 21 76 45 10 5 7 8 11 18 17 9 18 10 1 5 2 2 10 2 1 3 2 9 10 2 16 2 7 2 2 3 2 141 1 149 1 192 - The Italian national health service

– resolving problems related to structural defi- In Italy, a number of the above structures, both ciencies in the health system. public and private, provides specialist treat- Law No. 39 of 26 February 1999, article 1, sub- ments (Table X.7). On average, there are more section 6, makes provision for the allotment of private than public outpatient clinics, although 150 billion ITL to set up home care and hospice this depends largely on the area of Italy consid- schemes, with special reference to seriously ill ered. The public clinics are mainly located in patients. hospitals and other health structures. As far as the rehabilitation centres are con- 5.3 Specialist treatment cerned, the situation in 1997 is described in Table X.8. Specialist treatment includes: • Clinics and laboratories: public and private 5.4 Hospital care clinic and laboratories under contract with the INHS providing specialist examinations, clinical The INHS guarantees hospital admission for analyses and other diagnostic examinations conditions that cannot be treated on a home or (e.g. X-rays, echograms and CAT scans); outpatient basis, as well as for interventions in • Family planning clinics: family planning day hospital structures. clinics dealing with such issues as infancy-relat- Most general hospitals include at least four ed problems, women’s health, sex information basic services: general medicine, surgery, paedi- and education, contraceptives, pregnancy pro- atrics, gynaecology and obstetrics. tection and menopause problems; these also Depending on referral by a GP, care is provided provide counselling services for couples and free of charge in public hospitals or in private assist women requesting abortion; facilities under contract with the National • Drug services for addiction, prevention Health Service. Patient choice is respected and and rehabilitation: public service for drug as a result there are important cross-border addiction prevention and rehabilitation (SerT) flows between Regions and self-governed which provides users with psychological and Provinces, even though all have at least one social support, monitors the state of health of general hospital. Hospital services are mainly drug addicts and the diseases associated with free of charge at the point of use. drug-addiction, administers pharmacological The yearly figures for hospital care services are and other detoxicating therapies; implements as follows (Tables X.9 - X.14): therapeutical and rehabilitation programmes, • about 10 million admissions (on average, and gives support to other organizations pro- 300 000 inpatients per day), of which about viding similar services; 1.8 million in day hospital structures; • Departments for mental health: centres • about 80 million days of hospitalization; for mental health that guarantee specialist care • over 3 million surgical operations (on average, to people suffering from psychological disor- 8 000 surgical operations per day). ders. These centres actively promote discharg- The number of beds available in different ing patients from mental hospitals and inte- Regions of Italy is shown in Figures X.13 and grating them socially either at home or within X.14. As far as the comparison with other EU residential or semi-residential settings; countries is concerned, Italy ranks in the middle • Rehabilitation centres: rehabilitation cen- both for the number of hospitals and beds tres which guarantee outpatient and semi-resi- available to the population (Figure X.15). From dential care to the disabled and the elderly, Figure X.15 and from the comparison of data leading to their functional rehabilitation and for Italy in 1993 and 1997 (i.e. 6.6 beds/1 000 social reintegration; they also provide prosthe- people versus 5.8 beds/1 000 people), it can be ses and technical aids for the disabled. seen that the total number of hospital bed has The Italian national health service - 193 FACILITIES 1 others structures operating at local level. others structures , 1999. FACILITIES LABORATORIES SERVICES 1 OUTPATIENT OTHER SEMI- RESIDENTIAL OUTPATIENT OTHER SEMI- RESIDENTIAL CLINICS AND OUTPATIENT RESIDENTIAL FACILITIES CLINICS AND OUTPATIENT RESIDENTIAL FACILITIES LABORATORIES SERVICES REGION PUBLIC FACILITIES FACILITIES ACCREDITED PRIVATE Dialysis centres, hydrothermal establishments, mental health centres, maternal and child consulting rooms, district centres and maternal district centres establishments, mental health centres, and child consulting rooms, hydrothermal Dialysis centres, Table X.7: Public and private health care facilities in Italy by type – 1997. X.7: Public and private health care Table PIEMONTE D’AOSTAVALLE LOMBARDIA AUTON. BOLZANOPROV. AUTON. TRENTOPROV. VENETOFRIULI VENEZIA GIULIA 129LIGURIAEMILIA ROMAGNA 5 305 32TOSCANA 505UMBRIA 123 58MARCHELAZIO 391 27 13ABRUZZO 145 856MOLISE 218 83CAMPANIA 2PUGLIA 210 53BASILICATA 619 184 120CALABRIA 359SICILIA 36 96 169SARDEGNA 165 5 135 470ITALY 103 213 335 35 18 33 65 Dipartimento Programmazione, Flussi informativi delle ASL e Aziende Ospedaliere Source: SIS, Ministry of Health Italy, 232 57 22 751 57 28 26 93 373 119 63 131 330 384 169 91 154 3 8 103 30 39 6 15 350 31 182 202 32 10 59 1 57 12 4 268 59 271 25 1 70 242 22 26 4 66 20 332 3 813 16 24 36 2 5 109 1 36 13 5 22 77 102 695 1 21 151 7 621 6 1 031 9 24 18 18 23 1 088 7 52 50 10 1 1 24 2 312 10 53 33 85 2 216 37 5 5 065 1288 166 127 7 39 1 196 5 6 8 1 11 4 6 5 147 7 2 1 3 22 732 12 1 5 2 194 - The Italian national health service 6280 3034 55 501968 4 1116 29721 466 405 333 40 400 , 1999. FACILITIES FACILITIES FACILITIES FACILITIES RESIDENTIAL SEMI-RESIDENTIAL RESIDENTIAL SEMI-RESIDENTIAL MONITORED BEDS MONITORED BEDS REGION PUBLIC FACILITIES FACILITIES PRIVATE LOMBARDIA AUTON. BOLZANO PROV. AUTON. TRENTOPROV. VENETO FRIULI VENEZIA GIULIALIGURIAEMILIA ROMAGNA TOSCANAMARCHE 1LAZIO 28ABRUZZO 2MOLISECAMPANIAPUGLIABASILICATA 15 2 872CALABRIASICILIA 2 109SARDEGNA 40ITALY 217 2 3 1 15 37 87 1 8 3 48 91 3 2 27 12 10 16 94 40 3 016 36 62 10 91 3 256 32 1 304 46 10 52 13 249 345 374 92 764 6 9 7 5 1 675 149 380 756 714 38 273 1 993 750 655 907 11 813 1145 567 20 151 40 7 844 1 066 Table X.8: Rehabilitation institutes or centres in Italy – 1997. X.8: Rehabilitation institutes or centres Table PIEMONTE Dipartimento Programmazione, Flussi informativi delle ASL e Aziende Ospedaliere Source: SIS, Ministry of Health Italy, The Italian national health service - 195

Figure X.13: Number of Hospital beds in public health care facilities per 1 000 inhabitants in Italy - 1997.

less than 4.3

between 4.3 and 4.8 between 4.8 and 5.6

more than 5.6 National average: 4.8 hospital beds per 1.000 inhabitant

Source: SIS Ministry of Health of Italy. Dipartimento Programmazione, Flussi informativi delle ASL e delle Aziende Ospedaliere, 1999. fallen significantly in recent years. The reasons containment policies, changes in technology or for these changes are not well documented, methods of treatment, as well as changes in the but they probably reflect a combination of cost- roles of PHC and social care. Furthermore, in 196 - The Italian national health service

Figure X.14: Number of accredited beds in private health care facilities per 1 000 inhabitants in Italy - 1997.

less than 0.5

between 0.5 and 1 between 1 and 2

more than 2

National average: 1 hospital bed per 1.000 inhabitant

Source: SIS Ministry of Health of Italy. Dipartimento Programmazione, Flussi informativi delle ASL e delle Aziende Ospedaliere, 1999.

most countries, there has been an increase in accompanied changes in the management of admission rates, together with a reduction in patients, improvements in clinical techniques average length of stay. The latter trend has such as minimally invasive surgery, and incen- The Italian national health service - 197

Figure X.15: Hospital beds in the WHO European Region - 1980 and 1994.

Source: WHO, 1997c.

Figure X.16: Distribution of hospital beds by specialist sector within Local Health Agencies and other public health care facilities – 1997.

Source: Ministry of Health of Italy, 1999. 198 - The Italian national health service MONITORED EXISTING BEDS ACCREDITED TOTAL MONITORED EXISTING a/ , 1999. OTHER REMAINING LHA b/ BEDS IN PUBLIC FACILITIES PUBLIC FACILITIES FACILITIES HOSPITALS HOSPITALS INSTITUTES HOSPITAL DIRECTLY- UNIVERSITY IRCCSs UNIVERSITY DIRECTLY- HOSPITAL AGENCIES MANAGED HOSPITALS HOSPITALS PSYCHIATRIC INPATIENT REGION Local Health Agency Includes both main and secondary locations Table X.9: Beds available in public health care facilities and accredited beds in Italy by type – 1997. facilities and accredited X.9: Beds available in public health care Table PIEMONTE D’AOSTAVALLE LOMBARDIA AUTON. BOLZANOPROV. AUTON. TRENTOPROV. VENETOFRIULI VENEZIA GIULIA 5 721LIGURIA 13 868EMILIA ROMAGNA 10 288 3 418 2 393 19 448TOSCANAUMBRIA 2 264 519 2 303MARCHE 5 835LAZIO 4 258 277ABRUZZO 11 186 16 795MOLISE 3 253 620 5 015CAMPANIA 357 4 732PUGLIA 1 530 3 985 937BASILICATA 1 635 10 375 126 1 504CALABRIA 2 389SICILIA 2 010 378 108 261 3 852 5 082SARDEGNA 208 4 918 698ITALY 42 458 9 526 631 233a/ 1 322 18 372 8 667 100 147 5 667 935b/ 3 746 5 538 2 243 791 60 1 991 147 10 403 1 476 1 793 1 771 249 122 344 29 8 493 4 565 8 628 580 62 6 481 2 141 483 772 703 2 758 2 422 55 47 3 240 6 532 5 331 20 70 912 23 327 644 13 17 568 379 55 37 9 2 258 1 698 140 457 20 288 81 519 100 49 1 391 14 39 1 069 8 560 561 285 9 89 9 432 65 607 81 11 909 21 998 1 49 40 442 30 1 176 190 9 360 313 208 5 4 138 88 15 207 1 5 226 15 18 094 30 35 5 6 998 89 5 38 644 7 019 16 5 69 12 942 2 246 39 110 432 8 3 645 250 442 39 19 027 39 99 71 2 929 2 604 10 76 100 39 5 873 942 18 525 30 2 11 77 1 076 64 52 799 5 538 6 897 1 576 83 30 508 1 949 14 73 190 24 6 873 2 706 34 537 84 7 29 14 38 13 4 25 36 3 445 35 7 1 417 38 13 49 1 402 4 3 204 12 9 49 88 60 36 12 11 2 1 36 3 1 Source: SIS, Ministry of Health of Italy, Dipartimento Programmazione, Flussi informativi delle ASL e Aziende Ospedaliere Source: SIS, Ministry of Health Italy, The Italian national health service - 199 1 11 25 13 19 , 1999. HOSPITALS LOCATION LOCATION HOSPITALS INSTITUTES HOSPITAL DIRECTLY-HOSPITAL UNIVERSITY IRCCSsTOTAL OTHER HEALTH REMAINING LOCAL REGION AGENCIES MANAGED MAIN HOSPITALS INPATIENT SECONDARY HOSPITALSAGENCIES PSYCHIATRIC Table X.10: Public health care facilities in Italy by type – 1997. X.10: Public health care Table PIEMONTE D’AOSTAVALLE 7 42 1 ITALY Dipartimento Programmazione, Flussi informativi delle ASL e Aziende Ospedaliere Source: SIS, Ministry of Health Italy, 2 5 85 2 707 4 10 62 30 19 40 36 15 942 LOMBARDIA BOLZANO AUT. PROV. TRENTO AUT. PROV. VENETO GIULIAFRIULI V. LIGURIAEMILIA ROMAGNATOSCANAUMBRIA 16MARCHELAZIOABRUZZO 8 3MOLISE 93 11CAMPANIA 5 2PUGLIABASILICATA 3 13CALABRIA 41 4 65SICILIASARDEGNA 2 1 20 4 13 33 3 9 7 31 2 5 1 6 62 25 1 4 52 6 6 2 1 17 12 2 62 1 2 33 2 1 1 1 29 59 12 1 4 8 1 1 2 2 3 2 1 4 2 3 1 1 2 2 147 1 8 1 3 1 14 1 4 1 1 3 3 20 49 5 81 1 1 30 2 3 39 2 3 39 89 71 77 7 38 36 84 200 - The Italian national health service , 1999. POPULATION) (DAYS) ACTUALLY ACTUALLY ADMISSIONS ADMISSIONS BED DAYS LENGTH AVERAGE OCCUPANCY MONITORED EXISTING 28 - Spinal units 56 - Recovery and functional rehabilitation 60 - Long-term hospitalization REGION USED BEDS (PER 1 000 RATE OF STAY % RATE FACILITIES FACILITIES Table X.11: Admissions in public acute care* hospitals in Italy – 1997. X.11: Admissions in public acute care* Table PIEMONTE D’AOSTAVALLE LOMBARDIA AUTON. BOLZANOPROV. AUTON. TRENTOPROV. VENETO 2 327FRIULI VENEZIA GIULIALIGURIA 2 250 17 033 519EMILIA ROMAGNA 37 785TOSCANA 83 666 6 165UMBRIA 558 777 76 531MARCHE 1 318 476 18 877LAZIO 16 674 171 545ABRUZZO 21 333 184.2MOLISECAMPANIA 130.1 164.8 621 121 8 405 147.2 158.3PUGLIA 14 959 772 964BASILICATA 144.6CALABRIA 619 418 3 622 279 508SICILIA 4 771 459 10 765 883 6 923 523 695SARDEGNA 595 841 157.7 157 078 20 873 5 409 173.6 1 397 380 ITALY 129 987 16 555 235 630 1 531(*) Not including: 169.3 7.4 4 684 443 731 121 2 677 148.6 219 813 18 669 8.5 8.2 6 190 895 22 - Remaining mental hospitals 653 769 7.8 8.3 6 782 8.1 156.6 58 892 162.8 6 404 2 395 794 17 688 734 193 Dipartimento Programmazione, Flussi informativi delle ASL e Aziende Ospedaliere Source: SIS, Ministry of Health Italy, 75.9 98 102 4 016 881 79.2 78.6 140.1 172.6 237 818 7.5 73.0 113.0 82.8 234 583 8.0 66.6 208 264 751 968 1 892 094 938 062 178.1 127 9 179.6 8 484 717 57 161.4 8.6 6 133 541 1 561 768 10 7.7 80.1 4 356 702 114.7 1 79.9 18 125.2 147.4 445 417 129 4 739 022 8.0 7.2 81.1 57 9 147.7 665 043 47 1 522 041 77.2 11 8.4 7.1 75 6.7 18 1 518 249 1 4 744 811 78.9 71.8 64 111 822 27 7.6 6.5 38 47 82.3 82.7 6.8 75 6.4 77.3 7.3 38 10 6.3 80.0 27 72.7 7.6 39 81 23 68.2 71.9 64 70.2 75.6 38 10 73 7 77.5 84 24 13 37 67 33 81 869 74 7 13 37 34 82 883 The Italian national health service - 201 01 , 1999. ACTUALLY ADMISSIONS BED LENGTH AVERAGE OCCUPANCY MONITORED EXISTING 28 - Spinal units 56 - Recovery and functional rehabilitation 60 - Long-term hospitalization REGION USED BEDS DAYS (DAYS) OF STAY % RATE FACILITIES FACILITIES *) Including: 22 - Remaining mental hospitals Source: SIS, Ministry of Health of Italy, Dipartimento Programmazione, Flussi informativi delle ASL e Aziende Ospedaliere Source: SIS, Ministry of Health Italy, LOMBARDIA BOLZANOPROV..AUTON. AUTON. TRENTOPROV. VENETOFRIULI VENEZIA GIULIALIGURIAEMILIA ROMAGNA 95TOSCANA 508UMBRIA 4 673MARCHELAZIO 316ABRUZZOMOLISE 490 4 118CAMPANIA 1 994 894 31 850PUGLIABASILICATA 3 364 1 027CALABRIASICILIA 248 17 912 158 521 1 412 764 24 789SARDEGNA 5 123 23 96 3 119 95 693 1 125 129 1 539 36.6 38.5 44.4 3 465 561 533 45 220 754 28.4 29 358 205 307 197 986 5 962 2 383 91 94.4 87.8 85.2 3 742 22.7 493 43.1 72 758 837 508 98.5 85.3 2 951 395 4 422 60 358 614 26 228 3 7 40 378 21.0 355 272 87.1 739 88.4 2 131 446 6 89.1 16 663 115 687 21.6 60.1 60 26.6 45 16.9 3 8 94.9 27 6 379 84.1 14 935 278 595 82 896 8 32.8 6 39.2 53.3 89.7 74.5 46 16.1 31 95.8 8 82.5 20.2 130.7 185.9 101.4 8 14 88.6 1 4 12 7 84.6 8 59.1 91.7 53.7 1 16 9 2 4 13 1 8 6 9 3 1 12 1 11 7 4 Table X.12: Admissions in public non acute care* hospitals in Italy – 1997. X.12: Admissions in public non acute care* Table PIEMONTE D’AOSTA VALLE 1 339 9 075 409 689ITALY( 45.1 90.5 15 366 29 105 395 36 4 473 994 42.4 84.4 257 282 202 - The Italian national health service , 1999. POPULATION) (DAYS) ACCREDITED ADMISSIONS ADMISSIONS BED LENGTH AVERAGE OCCUPANCY MONITORED EXISTING 28 - Spinal units 56 - Recovery and functional rehabilitation 60 - Long-term hospitalization REGION BEDS (PER 1 000 RATE DAYS OF STAY % RATE FACILITIES FACILITIES Table X.13: Admissions in private accredited acute health care* facilities in Italy – 1997. acute health care* X.13: Admissions in private accredited Table PIEMONTELOMBARDIA AUTON. BOLZANOPROV. AUTON. TRENTOPROV. VENETOFRIULI VENEZIA GIULIA 160LIGURIAEMILIA ROMAGNA 98 2 050 7 031TOSCANAUMBRIA 517 2 353MARCHELAZIO 224 201 36 266 2 314 3 628ABRUZZO 1 029MOLISE 14 664 5.2CAMPANIAPUGLIA 25.0 80 8.4 88 108 1 825 5.0BASILICATA 30 152 12.4CALABRIA 175SICILIA 876SARDEGNA 51 156 1 545 740 22.4 32 082 1 238 4 830 900 6.8 475 340ITALY 22 604 4 830 112 543(*) Not including: 8 327 26 336 88 21.7 6.9 112 286 1 809 26 946 22 - Remaining mental hospitals 9.1 13.1 60 764 722 0.5 2 498 162 756 9.8 312 629 7.7 Dipartimento Programmazione, Flussi informativi delle ASL e Aziende Ospedaliere Source: SIS, Ministry of Health Italy, 10.0 88.7 18.2 1 275 3 350 2 995 66.1 21.5 54 227 21.2 76.2 8.7 1 355 78 821 28.1 271 424 63.2 10.4 37 447 60.5 13 146 32 357 107 931 4 54 9.1 13.3 228 294 52 825 1 289 871 26 66.8 1 045 377 38.0 314 698 84.0 8.5 2.2 1 103 543 2 14.6 5 21.2 54 6.3 4 27 11.5 8.7 6.3 18.2 32 11.7 402 021 46.0 14 24 725 6.8 2 46.0 561 348 5 12 217 76.3 72.4 89.2 751 599 35 260 134 72.6 15 8 570 579 25 7.4 69.7 8.3 7.1 1 9.0 53 12 7.0 4 8.0 25 66.7 8 77.0 8.2 60 65.1 2 55.8 58 12 64.3 56.6 4 10 28 69 68.0 2 33 1 49 12 34 425 33 2 1 49 12 453 The Italian national health service - 203 (DAYS) , 1999. ACCREDITED ADMISSIONS BED DAYS LENGTH AVERAGE OCCUPANCY MONITORED EXISTING 28 - Spinal units 56 - Recovery and functional rehabilitation 60 - Long-term hospitalization REGION BEDS OF STAY % RATE FACILITIES FACILITIES *) Including: 22 - Remaining mental hospitals Source: SIS, Ministry of Health of Italy, Dipartimento Programmazione, Flussi informativi delle ASL e Aziende Ospedaliere Source: SIS, Ministry of Health Italy, Table X.14: Admissions in private accredited non acute health care* facilities in Italy – 1997. non acute health care* X.14: Admissions in private accredited Table PIEMONTELOMBARDIA AUTON. BOLZANOPROV. AUTON. TRENTOPROV. VENETOFRIULI VENEZIA GIULIALIGURIA 48EMILIA ROMAGNATOSCANA 344 1 190 1 597UMBRIAMARCHE 90LAZIOABRUZZO 665 5 423 11 871CAMPANIA 25 949 510 147PUGLIACALABRIA 1 022SICILIA 30SARDEGNA 17 346 133 656 779 414 552 509 628 4 505 3 086ITALY 15 200 27 862( 8 112 1 043 179 26.1 7 354 24.6 15 34.9 19.6 93 253 49 824 140 706 1 366 501 27.3 23 272 106.4 99.0 127 99.8 5 771 3 620 95.9 241 988 95 4 638 20.7 16.1 15 352 1 094 4 601 84.8 2 599 886 61 373 4 20 3 986 1 41 223 446 76 140 742 32.9 1 501 309.2 79.9 92.9 102 358 1 189 040 111.7 52 953 44.9 22 4 42 5 87.5 8.0 38.7 42.4 20 21.0 51 033 24 360 4 774 964 5 88.8 84.1 1 41.1 48.4 72.8 13 60.9 116.5 1 23 68.8 16.2 8 46.6 55 103.6 77.8 3 10 1 13 2 110.1 1 73.1 88.5 55 11 3 4 12 1 3 197 3 3 11 6 219 3 5 204 - The Italian national health service

tives to reduce length of stay and ensure that munities which allow their rehabilitation and patients who no longer need acute care are dis- social integration. In this context, they are given charged to other facilities. psychological assistance to solve their problems Nearly 80% of all beds are allocated to med- and are encouraged to acquire a new life-style. ical/surgical activities (Figure X.16). In more While living in the community, they work or recent years, the progressive ageing of the attend vocational training courses. population and decreasing birth rate has led to a reduction in the number of beds in medical- surgical and maternity-children’s wards, as 6. HUMAN RESOURCES well as an increase in the number of beds in such wards as rehabilitation and long-term In 1997, about 480 000 people were employed care. On the other hand, a significant increase in Local Health Agencies in Italy (Table X.15), of has been observed in the number of public which approx. 65% were physicians (including health care centres with transplant depart- the general practitioners referred to in section ments (particularly kidneys, heart, liver and 5.2), dentists or nurses. An additional number lungs). of about 302 000 people were employed in hospitals and similar institutions (Figure X.17) 5.5 Care and rehabilitation of non self-suf- managed by Local Health Agencies, with an ficient persons average physician/nurse ratio of 2.63.

This service provides admission to specially designed sheltered facilities for the rehabilita- 7. HEALTH CARE QUALITY tion of persons who are not self-sufficient with a view to their social reintegration: 7.1 Management of quality • Persons with mental disorders: the INHS takes care of patients suffering from long-term Only some countries have set their own spe- psychiatric disorders by providing accommoda- cific targets and indicators, and far too few tion in sheltered residential settings (e.g. half- use health outcomes as the main parameter way homes, community-type housing). The for managing the health sector. Even fewer elderly are given health care and shelter in so- countries use health outcomes as the main called health care residences, which are staffed parameter for managing individual health ser- by physicians, nurses, rehabilitation therapists vice institutions. Almost no country, either in and psychologists; the European Region or elsewhere, has a sys- • The disabled: the INHS provides the disabled tem where all clinicians receive continuous (either from birth or as a consequence of dis- feedback on the results of their own patient ease or trauma) with specialist residential care care. in rehabilitation centres. The activities of these This situation reveals some very serious flaws in centres aim to re-gain the use of disabled health care management practice, as they pre- limb(s) and subsequently re-integrate patients vent the health system from being properly into their family and work environment. These focused and lead to much current practice in centres are staffed with specialist physicians the European Region being below the assumed (psychiatrists, orthopaedists, neurologists, etc.), quality. It is also wasteful of resources. The rehabilitation therapists (physiotherapists, major challenge in health care for all Member speech therapists, occupational therapists), psy- States in the European Region is, therefore, to chologists and nurses; refocus the management of health services and • Drug users: the INHS provides drug users care towards measuring the true impact of dif- with care facilities in specially designed com- ferent interventions on the health of the popu- The Italian national health service - 205

Figure X.17: Nurse/doctor ratio in local health agency hospitals in Italy - 1997.

less than 2.2

between 2.2 and 2.6

between 2.6 and 3 more than 3

Source: SIS Ministry of Health of Italy. Dipartimento Programmazione, Flussi informativi delle ASL e delle Aziende Ospedaliere, 1999.

lation; the use of health outcome indicators Outcome indicators help to measure which would offer a unifying practical concept for interventions are effective. They should be used doing precisely this. for monitoring daily patient care and for assess- Information systems at all levels should clearly ing new diagnostic and therapeutic technolo- support informed management and continuous gies (including new pharmaceutical products quality development. However, in the European and medical equipment) during both initial tri- Region, most health services institutions and als and subsequent routine use. They can also providers currently lack basic information about become an important tool in new management the quality of the care that they provide in their techniques, such as monitoring the health ser- daily practice. vices and care provided. This has implications 206 - The Italian national health service

Table X.15: Employees of Local Health Agencies in Italy - 1997.

OF WHICH

REGION TOTAL PHYSICIANS NURSES AND DENTISTS

PIEMONTE 34 130 5 318 12 339 VALLE D’AOSTA 1 726 243 575 LOMBARDIA 66 008 8 348 24 757 PROV.AUT. BOLZANO 6 721 689 2 678 PROV.AUT. TRENTO 6 494 786 2 510 VENETO 46 272 6 225 20 355 FRIULI VENEZIA GIULIA 9 067 1 130 3 696 LIGURIA 14 938 2 010 5 823 EMILIA ROMAGNA 38 883 5 738 15 199 TOSCANA 36 233 4 855 14 777 UMBRIA 7 080 1 112 2 733 MARCHE 13 368 1 765 5 162 LAZIO 39 631 6 075 14 472 ABRUZZO 14 859 2 251 5 923 MOLISE 3 945 707 1 382 CAMPANIA 41 719 7 024 15 377 PUGLIA 28 069 3 772 9 804 BASILICATA 4 516 662 1 599 CALABRIA 17 617 2 709 5 332 SICILIA 29 017 4 985 9 093 SARDEGNA 19 747 3 289 6 903

ITALY 480 040 69 693 180 489

* Also including other professionals.

Source: SIS, Ministry of Health of Italy, Dipartimento Programmazione, Flussi informativi delle ASL e delle Aziende Ospedaliere, 1999.

for the work of public health management times very large) variations in the outcomes of experts. care. Such differences are found not only Until recently, it was generally assumed that between countries or Regions within coun- well-trained physicians and other care workers tries, but also between institutions, hospital who had systematic access to information departments and individual health care about scientific innovations and who were providers. working in well-equipped health care institutions would automatically produce homoge- 7.2 Avoidable deaths neous and high-quality health care. However, a steadily mounting body of evidence shows The use of “avoidable death” as an indicator of that this is not the case and that, in spite of the quality of medical care was based upon pre- existing knowledge, there are wide (and some- vious experience and was further developed in The Italian national health service - 207

TARGET 16 – HEALTH21

By the year 2010, Member States should ensure that the management of the health sector, from population-based health programmes to individual patient care at the clinical level, is oriented towards health outcomes.

In particular: 16.1. the effectiveness of major public health strategies should be assessed in terms of health outcomes, and decisions regarding alternative strategies for dealing with individual health problems should increasingly be taken by comparing health outcomes and their cost-effectiveness; 16.2. all countries should have a nationwide mechanism for continuous monitoring and development of the quality of care for at least ten major health conditions, including measurements of health impact, cost-effectiveness and patient satisfaction; 16.3. health outcomes in at least five of the above health conditions should show a significant improvement, and surveys should show an increase in patient’s satisfaction with the quality of services received and heightened respect for their rights.

the 1970s in the United States by Rutstein (Rut- A detailed analysis of avoidable deaths in Italy stein et al., 1976), who proposed a list of sen- was carried out in the 1996 report on “The tinel health events9 which, through various Health Status of the Nation” (Ministry of revised versions, has been subsequently used by Health, 1996). A summary of the main results other authors in other countries (Marshall et al., of this analysis is reported below. 1993; Charlton et al., 1983; Carr-Hill et al., Table X.16 shows the list of causes of death by 1987; Poikolanen et al., 1986; Boys et al., type which should be prevented by appropriate 1991; Mackenbach et al., 1988; De Marco et medical and/or public health intervention. The al., 1990; Buiatti et al., 1988; Lauriola et al., first group includes those causes for which 1989). In 1986, Holland and collaborators, with major aetiological factors have been identified financial assistance from the Commission of the and whose impact should be reduced through European Community, published and subse- adequate primary prevention. Obviously, the quently updated a European Community Atlas impact of prevention varies from disease to dis- of “avoidable death” (EC, 1993). As in most of ease. The second group includes neoplastic dis- the studies on this subject, the analysis is eases for which early diagnosis, followed by restricted to the age group 5-64 and to both appropriate therapy, has been shown to largely sexes, as in this age group the mortality rate is increase patient survival rates. The third group more affected by failures of medical interven- is more heterogeneous and is formed by dis- tion and prevention. eases associated with poor hygienic conditions,

9 This terminology was introduced into the medical field by D.D. Rutstein, who identified a series of events which, in principle, should never occur (in particular, avoidable deaths, that is deaths which modern medicine can prevent, e.g. death from appendicitis). Their occurrence, even in a single instance, is a symptom of the inef- ficiency of a medical unit or of a hospital or of other types of medical services, or more generally, of a lack of preventive health care, of insufficient national health services, etc. 208 - The Italian national health service

Table X.16: Causes of “avoidable” deaths by type of public health intervention.

ICD IX

Primary Prevention – Malignant neoplasm of the upper aereo-digestive tract 140-150.61 – Malignant neoplasm of the liver 155 – Malignant neoplasm of the lung 162 – Malignant neoplasm of the bladder 188 – Cerebrovascular diseases 430-438 – Cirrhosis of the liver 571 – Accidental deaths 800-999

Early diagnosis and Therapy – Malignant neoplasm of the skin 173 – Malignant neoplasm of the breast 174 – Malignant neoplasm of the cervix uteri 180 – Malignant neoplasm of the corpus and cervix uteri 179-182 – Malignant neoplasm of the testicle 186 – Hodgkin’s disease 201

Hygiene Conditions and medical care – Infectious intestinal diseases 000-009 – Tuberculosis 010-018 – Hepatitis 070 – Infectious diseases 000-139 – Leukaemia 204-208 – Chronic rheumatic heart disease 393-398 – Hypertensive diseases 401-405 – Ischemia 410-414 – Pneumonia and bronchitis 480-484 – Acute respiratory diseases 485-486 – Asthma 493 – Respiratory diseases 460-519 – Ulcer of the stomach and duodenum 531-534 – Appendicitis 540-543 – Abdominal hernia and intestinal occlusion 550-553 – Acute and chronic cholecystitis 574-575 – Maternal deaths 630-676 – Congenital heart anomalies 745-747 – Infant mortality 760-779

Source: Bellini et al., 1993 The Italian national health service - 209

e.g. viral hepatitis A, and other diseases which 64-year-old men and women in Italy by the are strongly influenced by the efficiency of the three groups of preventable causes in the time public health system in providing a correct diag- periods 1980-1982 and 1990-1992. For both nosis and an appropriate treatment in due time men and women, the death rates decreased in (as is the case of acute appendicitis). From the early 1990s compared to early 1980s. above definitions, it is clear that these data and An analysis of selected causes of death which consequent analyses must be interpreted with could have been prevented through appropri- caution. It should be noted that the classifica- ate medical interventions can give useful infor- tion adopted varies within different countries, mation for assessing the quality of specific therefore these results might be due to varia- medical services, such as surgery or emergency tions in terms of categorisation criteria for rooms. An example of such an approach is “avoidable deaths”. given in Figure X.18, where data on mortality Table X.17 shows a comparison among avoid- by acute appendicitis in Italy and the EU coun- able death rates in Italy and in some of the tries in the period 1970-1993 is reported. European countries. Italy shows a rate of 7.0 Deaths rates in Italy decreased sharply during per 10 000 population for avoidable deaths the last 20 years, moving from a rate of 1.22 in attributable to medical care; this is the lowest 1970 to 0.09 per 100 000 population in 1993. value in men among the selected groups of The latter value is below the EU average, which countries considered. As for the group of caus- moved from 1.28 in 1970 to 0.31 in 1993. es amenable to primary prevention, Northern Continuous quality development using docu- countries have a death rate of 11.2 per 10 000 mented outcome measurement and evidence- population, which is the lowest for this group. based medicine contributes to more effective Among women, Italy shows a death rate of 3.8 applications of diagnostic and curative inter- and 2.2 for avoidable deaths associated to poor ventions as well as to a reduction of unneces- primary prevention and medical care; these two sary expenditure on procedures and pharma- values are the lowest for these groups. ceuticals. Table X.18 shows number of “avoidable” The education and training of health profes- deaths and rates per 10 000 population in 5- sionals must equip them with the skills required

Table X.17: Standardized rates per 10 000 population aged 5-64 of “avoidable” deaths by group of causes and by sex. Italy and selected Regions in Europe. 1990-1992*.

RATES+ PER 10 000 POPULATION

ITALY SOUTHERN CENTRAL NORTHERN EUROPE EUROPE EUROPE Men Primary prevention 15.2 15.9 16.6 11.2 Early diagnosis 0.1 0.1 0.2 0.2 Medical care and hygiene 7.0 7.6 7.8 13.8 Women Primary prevention 3.8 3.9 4.7 4.9 Early diagnosis 2.6 2.4 2.7 3.5 Medical care and hygiene 2.2 2.4 2.4 5.1

+Rates are standardised using the European population as a standard

*Source: Ministry of Health of Italy, 1996. 210 - The Italian national health service

Table X.18: Number of “avoidable” deaths and rates per 10 000 population of men and women aged 5–64 in Italy according to the three groups of preventable causes. 1980-1982 and 1990-1992*.

AVOIDABLE MORTALITY YEARS 1980-1982 YEARS 1990-1992 RATES CASES RATES CASES GROUP I: Primary prevention Men 19.15 117 780 15.53 107 606 Women 5.26 34 963 4.00 29 078 GROUP II: Early diagnosis and treatment Men 0.26 1 620 0.13 928 Women 2.86 18 873 2.56 18 190 GROUP III: Medical care Men 9.02 54 027 5.85 40 103 Women 3.00 19 833 1.81 13 365

Source: Ministry of Health of Italy, 1996.

Figure X.18: SDR for appendicitis in EU countries.

Source: WHO, 1999c. The Italian national health service - 211

to be active participants in this process, provid- organizational characteristics, such as health ing them with the means to assess the quality and safety regulations, administrative proce- and outcome of their clinical work as a neces- dures, staffing and training policies, procedure sary step in improving health care delivery. and policies for health care delivery and the Recently, some data of the “Prometeo Atlante processes used to produce them. della Sanità - 1999” research have become Problems encountered so far have been con- available and indicate that in 1994 there was a centrated around defining and assessing stan- total of around 60 000 avoidable deaths in Italy, dards and qualifying the surveyors employed. of which about 70% were men. According to Standards lie at the core of any accreditation this research, about 60% of these deaths could system and, therefore, their focus and the qual- have been prevented by primary prevention, itative level at which they are set are crucial 11% by early diagnosis and the remaining part when determining the acceptability and nature by improved health care. This study also proof the system. The main problems lie in ensur- vides a breakdown of avoidable deaths among ing uniformity in standards across the country, the different Local Health Agencies. as well as in assuring their validity, since the extent to which some of them relate to clinical 7.3 Health care quality assurance outcomes is not obvious. The credibility of the surveyors, as both fair and consistent in judge- Major ongoing quality assurance programmes ment, is critical for the success of the pro- in Italy include: gramme. While consistency is attainable • accreditation of health care facilities; through training and certification of surveyors, • clinical practice guidelines, in order to provide fairness largely depends on whose behalf they a sound evidence base for assuring and improv- are acting. ing the quality of clinical practice; • clinical performance measures, to assess the 7.3.2 Clinical Practice Guidelines extent to which providers deliver appropriate medical services; Quality is determined not just by having the • population-based, health related measures to “right” facilities available and providing an assess the goals of the Health Improvement Pro- appropriate environment for clinicians to prac- grammes included in the National Health Plan. tice and treat individual patients. It also (and mostly) means that the correct actions must be 7.3.1 Accreditation of health care facilities performed in the correct way. The importance of building the evidence base in order to Based on the health care reform Law, public strengthen the scientific basis of clinical prac- and private health care facilities are required to tice cannot be overstated. be certified by the Region. Participation in the Evidence-based Clinical Practice Guidelines pro- accreditation programme is mandatory for hos- vide physicians and other health care profes- pitals, outpatient clinics and long-term care sionals with scientific information about which public or private facilities providing services on treatments are most appropriate for which behalf of the INHS. Accreditation is provided by patients and at what point during the course of the Regions, which are entitled to develop their their care, in order to avoid using unnecessary own standards. Compliance with these stan- or inappropriate care, as well as underusing dards is periodically assessed by surveyors who necessary, effective and appropriate care. are external to and independent from the par- A rolling programme of development, diffusion ticipating health care facilities. and evaluation of Clinical Practice Guidelines To date, only a few Regions have set out their has been developed with particular focus on: standards, mostly relating to structural and • reducing variation in health care utilization; 212 - The Italian national health service

• addressing the over and underprovision of ity of its National Health Service. A first survey health services. has been completed by EURISKO on the basis A long-term implicit goal is to help define more of a methodology specifically studied for the precisely the extent of coverage offered by the evaluation of the perceived quality in health INHS, by identifying a set of essential or core care (QPSS: “Qualita’ Percepita dei Servizi Sani- services. For the first phase, the conditions con- tari”) (EURISKO, 1998). The survey was per- cerning preventive as well as diagnostic and formed by interviewing a representative sample therapeutic services have been selected on the of 10 000 people, from 14 years of age basis of general criteria, such as: onwards, in 1997. The results of the EURISKO • frequency in the general population or special study shows that 41% of the population sam- subsets; ple consider the service offered “barely satis- • direct or indirect costs; factory”, while 23% think it is “not at all satis- • availability of relevant information, including factory”. On the other hand, 34% think it existing guidelines; offers a fairly satisfactory service, and only 2% • evidence of variation in access to or use of of the sample consider it to be very satisfactory health care services. (Figure X.19). Figure X.20 summarises the proportion of posi- 7.4 Perception of care quality tive evaluations of the Italian National Health System between 1992 and 1997. After an ini- Similar to health care providers and purchasers, tial drop in 1993, the assessment improved the public needs good quality information, in over time, reaching a value of 36.1% in 1997. particular about what they can reasonably The same data disaggregated by Region are expect in terms of quality and outcome of care, reported in Figure X.21. Values range from in order to make meaningful choices, to have 19% in Sicilia, which has the lowest percent- an informed dialogue with health providers and age, to 53% in Emilia-Romagna, i.e. more than to decide how to organize their lives when they half of the population interviewed declared it are ill or receiving treatment. One explicit aim was satisfied with the Health Care System. of health care systems in the future should be Overall, these data confirm an improvement in to provide citizens and patients with more the quality of services provided to the citizens information in order to empower them and over time both measured through objective improve their health. indicators (avoidable deaths) and population Many European countries have chosen to adopt judgement. special legislation on patients’ rights. Another approach is to implement a widely accepted patients’ charter. The Declaration on the Pro- 8. PARTNERSHIPS FOR HEALTH motion of Patients’ Rights in Europe (Amster- dam, 1994) provides a useful framework for The implementation of health policies in Italy countries wishing to take action in this area. involves a number of partners including indi- Possibly the most significant effects of this vidual citizens, non-governmental organiza- trend are that patients will understand more tions, private operators and public institutions about their health condition and treatment, and administrators at all levels (national, and health care workers will become more regional and local). A good example of this respectful of patients’ needs and views and be wide-reaching participation is the successful more supportive in helping them to manage implementation in Italy of the WHO Healthy their own disease in a better way. Cities project: a long-term development project The Italian Ministry of Health has recently initi- which aims to place health issues high on the ated periodic assessments to monitor the qual- agenda of leaders and decision-makers in the The Italian national health service - 213

Figure X.19: The Italian National Health System - Judgement on the perceived quality (answer to the question: “How do you judge the quality offered by the Italian National Health System?”) – 1997.

Source: EURISKO, 1998.

Figure X.20: The evaluation of the Italian National Health System - Proportion of positive assessments over time - 1992 – 1997.

Source: Ministry of Health of Italy, 1999, in press. 214 - The Italian national health service

Figure X.21: Satisfaction for the Italian National Health System: analysis by Region - 1997.

Source:Ministry of Health of Italy, 1999, in press.

Figure X.22: National Healthy Cities Network in the WHO European Region - 1999.

Source: WHO, http://www.who.int/peh/Healthy_cities/hlthcit/index.htm. The Italian national health service - 215

TARGET 20 – HEALTH21

By the year 2005, implementation of policies for health for all should engage individuals, groups and organizations throughout the public and private sectors, and civil society, in alliances and partnerships for health.

In particular: 20.1 the health sector should engage in active promotion and advocacy for health, encouraging other sectors to join in multisectoral activities and share goals and resources; 20.2 structures and processes should exist at international, country, regional and local levels to facilitate harmonized collaboration of all actors and sectors in health development.

cities of Europe and to promote comprehensive some extent to other programmes intended to local strategies for “health for all” for the 21st be implemented at territorial level with a broad century. Approximately 1 100 cities and towns range of participation, such as the WHO pro- are linked with 26 national and several region- jects on health promoting schools and hospi- al and thematic (multi-city action plans) healthy tals. cities networks in Europe (Figure X.22). Cities In Italy, excellent examples of mobilization of participating in the WHO European network partnerships for health are also provided, by have developed and implemented a wide religious and other non-governmental organi- range of programmes and products, including zations, whose role in alleviating suffering and city health profiles (e.g. health profile of the fighting for health is very important. Some city of Bologna, 1996) and city health strate- organizations are active and successful in orga- gies based on intersectorial cooperation, com- nizing periodic fund-raising campaigns, jumble munity development initiatives and pro- sales and other similar initiatives to promote sci- grammes that address the needs of vulnerable entific research on diseases, such as pro- groups, lifestyles, environmental health and grammes against cancer and dystrophy. Agenda 21. In Italy, the National Healthy Cities Considerable momentum for the mobilization Network was set up at the end of 1995 when of a number of actors and sectors in health an agreement among 43 Italian municipalities development is also provided by the European was signed; since then, the number of munici- Union Programmes on a number of different palities in the network has increased enor- health matters, such as cancer, AIDS, drugs, mously. Similar considerations also apply to health promotion, injuries and rare diseases. CHAPTER XI

HUMAN RESOURCES AND RESEARCH FOR HEALTH

CONTENTS

1. HUMAN RESOURCES ...... 218 2. RESEARCH AND TRAINING BY PUBLIC INSTITUTIONS AND REGIONS ...... 221 3. EVIDENCE-BASED HEALTH SERVICES ...... 224 218 - Human resuorces and research for health

1. HUMAN RESOURCES health promotion and disease prevention are often undervalued. Furthermore, the nature of With some 1.5 million doctors, over 4.5 million the studies undertaken by different health pro- nurses and tens of millions of other health care fessionals is in a number of cases completely workers in the WHO European Region, human independently-based, and teamwork is seldom resources are a critical factor in all health ser- promoted. vices and are very important in policy and pro- Education has traditionally paid too little atten- gramme implementation. Various trends have tion to those elements of the professionals’ been observed throughout the Region. The work that are vital for population-based health. health services in the Eastern and Southern These “missing” elements include epidemio- parts of the WHO European Region have been logically based assessment needs, the principles overstaffed for some time, yet unemployment and practice of health promotion, disease pre- and other market forces have done little to vention and rehabilitative care, and regular reduce the number of physicians. In spite of evaluation and analysis of the quality of their overstaffing, a number of countries are still own work. Continuing professional education experiencing difficulties in staffing rural areas. is, in general, poorly developed. In many Member States, the shortage of appro- In Italy, there are a number of highly qualified priately skilled family health practitioners and schools of medicine and the number of gradu- nurses and other Primary Health Care staff is a ate physicians is quite high compared to other serious problem, while education for health European countries. professionals has become somewhat unbal- The ratio between population and doctors anced, often leading to over-specialised physi- varies markedly across Italian Regions (Figure cians and under-qualified nurses. In some cases, XI.1); the lowest values are reported in Puglia (1 the medical profession is oriented towards dis- doctor for 721 people) and the highest in ease alone, rather than to disease and health, Umbria (1:449) (Ministry of Health, 1999). and is confined to the hospital setting or even Even though the number of doctors is already limited to highly specialised care; therefore, reasonably high compared to other European

TARGET 18 - HEALTH21

By the year 2010, all Member States should have ensured that health professionals and professionals in other sectors have acquired appropriate knowledge, attitudes and skills to protect and promote health.

In particular: 18.1 the education of health professionals should be based on the principles of the HFA policy, preparing them to provide promotive, preventive, curative and rehabilitative services of good quality and helping to bridge clinical and public health practice; 18.2 planning systems should be in place to ensure that the number and mix of health professionals trained meet current and future health needs; 18.3 all Member States should have adequate capacity for specialised training in public health leadership, management and practice; 18.4 the education of professionals in other sectors should include the basic principles of the HFA policy and, specifically, knowledge of how their work can influence the determinants of health. Human resuorces and research for health - 219

countries, there are still many new graduate On the other hand, the dentist/inhabitant ratio physicians each year. The Italian value (15.33 has recently improved through the introduction per 100 000 population) is the second highest of university degree courses in dentistry, distinct in the EU after Germany (15.44 per 100 000); from general medicine, and has actually this is twice the value reported in the United become closer to the European average. How- Kingdom, Denmark or Sweden, for instance ever, it is still lower than other European coun- (Figure XI.2) (OECD, 1998). tries (Figure XI.3).

Figure XI.1: Population/doctor ratio in Italy by Region - 1997.

between 662 and 712 between 591 and 662 between 560 and 591 between 529 and 560 between 451 and 529

Source: SIS, Ministry of Health of Italy, Dipartimento Programmazione, Flussi informativi delle ASL e delle Aziende Ospedialiere, 1999. 220 - Human resuorces and research for health

Figure XI.2: Number of new graduate physicians per 100 000 population in selected European countries - 1996 or last available year.

Source: WHO, 1999c.

The number of physicians studying for post- This unbalanced situation between nurses graduate specialisations is planned annually in and physicians is also reflected in the data Italy by the Central Government and the spe- regarding the number of graduate nurses. cialised schools in the different disciplines com- Italy is once again below the European aver- ply with European Union regulations. age (Figure XI.6). The average number of nurses in Italy is lower Overall, these data demonstrate the urgent than that observed in other European countries need to even out the presence of different (Figure XI.4). health professions. Several decisions have been The national average ratio of nurse to inhabi- taken in this direction in recent years, including tant is 1:227, while regional values range from the re-organization of training profiles for 1:167 in Friuli in the North to 1:280 in Sicilia in health professions other than doctors (see Table the South (Figure XI.4). The nurse/physician XI.1) and the introduction of limited enrolments ratio, is 3.8:1 in the Province of Bolzano and in the medical schools of many universities and 1.9:1 in Sicilia. of dental schools in all universities. Human resuorces and research for health - 221

Figure XI.3 - Density of dentists per 1 000 population in selected European countries – 1995.

Source: OECD, 1998.

2. RESEARCH AND TRAINING BY PUBLIC lactic Institutes, University-managed hospitals, INSTITUTIONS AND REGIONS National Institute of Health and National Insti- tute for Prevention and Safety at work. Ad hoc A number of scientific Institutions active in the financial resources are arailable in Italy for this area of research also carry out training activities purpose. on a regular basis. These activities are designed The Health Care Institutes of a Scientific Charac- for either health personnel or post-graduate ter carry out both health care and research (see students. Training is carried out with some Annex 7). Moreover, they provide the National financial assistance from the national health Health System with technical and operational budget (e.g. see Annex 5). support for delivering health assistance and pur- In Italy, scientific research and training in the suing the National Health Plan targets in the field health care sector is mainly carried out by Med- of health research. They play, therefore, a crucial ical Schools and by the Health Care Institutes of role within the National Health System in identi- Scientific Character, Experimental Zooprophi- fying particular needs and responding to them, 222 - Human resuorces and research for health

Figure XI.4: Population/nurse ratio in Italy by Region - 1997.

between 277 and 292

between 238 and 277

between 209 and 238

between 184 and 209

between 169 and 184

Source: SIS, Ministry of Health of Italy, Dipartimento Programmazione, Flussi informativi delle ASL e delle Aziende Ospedialiere, 1999.

by sharing their scientific knowledge and opera- specialization and disease prevention, diagnosis, tional resources. This function not only obliges therapy and rehabilitation methods. University- these Institutes to respect the provisions laid managed hospitals provide health assistance, down by National and regional health planning, personnel training and research, and are partly but also to be consistent in terms of their own funded by the Ministry of Health. Human resuorces and research for health - 223

Figure XI.5: Density of nurses per 1 000 population in selected European countries – 1995.

Source: OECD, 1998.

The Experimental Zooprophylactic Institutes was concentrated in the following areas (see organize training activities for veterinary per- Annex 3): sonnel, carry out experiments on technologies • Pharmaceuticals and methods essential for the safety control of • Biotechnology feed-stuffs and foodstuffs of animal origin, as • Mental and neurological diseases well as pharmacological supervision of veteri- • Tumours nary medicine; they also guarantee epidemio- • Infective and parasitic diseases logical surveillance. • Metabolic, chronic-degenerative and cardio- The National Institute of Health is also very vascular diseases active in this area and is currently running a • Human genetics number of research projects. Some of these • Blood projects have a national dimension and some • Population health and health services others are carried out in cooperation with other • Health and environment European and non-European scientific institu- • Radiation tions. The research activity of the National • Food, nutrition and veterinary public health Health Institute during the period 1995-1997 • Quality assurance 224 - Human resuorces and research for health

Figure XI.6: Number of graduate nurses per 100 000 population in selected European countries - 1996 or last available year.

Source: WHO, 1999c.

Health personnel training is an important issue the INHS in Italy. A clear example of that is pro- in the regional education activity. Most of it is vided by the pharmaceutical policy. In accor- carried out at the Local Health Unit Agency and dance with existing regulations for marketing in Hospital Agency levels within the context of a Italy, medicaments are specifically examined by yearly planning schedule and in compliance the “Commissione Unica del Farmaco”, a with the provisions of Law No. 502/92. In national expert pharmaceutical Committee, response to an “ad hoc” survey carried out by whose task is, among others, to decide which the Ministry of Health in late 1998, which is still drugs are to be made available in pharmacies at ongoing, several regional Authorities provided no or partial cost for the patients (and the cor- some details of their health personnel training responding cost coverage by the Local Health programmes. These are summarized in Annex 6. Agencies). The Committee’s decisions are binding for the Government. Medicaments available on the market are classified into three cate- 3. EVIDENCE-BASED HEALTH SERVICES gories (Decree No. 537/1993):

Given the limited number of resources available • class A medicines: essential medicines and for health, evidence-based medicine is the main medicines for chronic diseases; no cost for the criterion for providing health treatments within patient; Human resuorces and research for health - 225

Table XI.1: List of non-medical health professions recognized by the Italian Ministry of Health

• Orthopaedist • Podiatrist • Audiometrician • Hearing aid technician • Dental hygienist • Nurse • Midwife • Physiotherapist • Speech therapist • Orthoptist • Dietician • Laboratory technician • Radiology technician • Neurophysiopathology technician • Psychomotor therapist for the elderly • Psychiatric and rehabilitative therapist • Occupational health technician • Health worker • Paediatric nurse • Occupational therapist • Education professional • Cardiovascular physiopathology technician

• class B medicines: other than those in class A ate, guidelines for prescription (so-called and of therapeutic relevance; patients pay fifty “notes”) are provided for each drug. The gen- per cent of the cost; eral practitioners have to comply with when • class C medicines: the remaining medicines, prescribing medicines at no or partial cost for also known as “comfort medicines”; patients patients (class A and B). pay for the whole cost. These guidelines have proven to be an extreme- When classifying medicines under class A or B, ly valuable instrument for general practitioners. the above-mentioned Committee not only This mechanism has generated a growing identifies each pharmaceutical component, but awareness of the rational use of medicines and also the specific dosages and therapeutic indi- has resulted in a significant contribution to their cations considered. In addition, when appropri- cost-effective use. CHAPTER XII

NATIONWIDE SOLIDARITY AGREEMENT

CONTENTS

1. HEALTH AS A FUNDAMENTAL RIGHT OF HUMAN BEINGS . . . . . 230

2. THE NEED FOR IMPROVEMENT ...... 230

3. IMPROVING REGIONAL AND LOCAL ACCOUNTABILITY ...... 230

4. AN AGREEMENT FOR HEALTH ...... 231

5. THE ITALIAN NATIONAL HEALTH PLAN (INHP): PRIORITIES ...... 232 5.1 Strengthening the health service users’ decision-making autonomy ...... 232 5.2 Promoting an appropriate use of health care services ...... 233 5.3 Overcoming health-related inequalities ...... 233 5.4 Fostering healthy lifestyles and attitudes ...... 233 5.5 Combating major diseases ...... 233 5.6 Helping patients to actively cope with chronicity ...... 233 5.7 Finalising the social-health integration process ...... 233 5.8 Promoting research ...... 234 5.9 Investing in human resources and system quality ...... 234 230 - Nationwide solidarity agreement

1. HEALTH AS A FUNDAMENTAL RIGHT OF of Italian health-targeted financial resources, HUMAN BEINGS both in relation to GDP and in per capita terms, is lower than those of some highly developed An efficient and appropriate health service is European countries and much lower than those one of the key-factors which enables all citizens of the United States and Canada. to assume their rightful place in participating in the social life of the community and to achieve their individual best in respect of the principle 2. THE NEED FOR IMPROVEMENT of equal opportunities. In order to enable users to effectively benefit In spite of its many achievements, the Italian from health services, financial, geographical National Health Service still requires many and social barriers need to be removed. This is changes and there is indeed room for improve- the goal pursued by Italy and achieved by ment. means of taxation-based financial procedures, The need to comply with the constraints equity-based service provision and free health imposed by the national financial recovery services at the point of use. objectives, which is further prompted by the Ensuring equal access to health care is the main European Union parameters, requires that all goal of the Italian National Health Service (INHS) the operators of the health system be commit- and of its financial and organizational criteria. ted to boosting its effectiveness. However, not only is the need for change a problem related to The INHS basic principles are: the country’s economic situation, it also stems • Universality of access to health care. Access to from other factors such as technological innova- health care should only depend on an accurate tion and the development of scientific know- assessment of health care needs and not be depen- how in the field of health care and health care dent on criteria of social or financial eligibility. organization, as well as demographic change • Equity. Geographical barriers hampering and social developments. Service restructuring access to health care should be eliminated and alone cannot respond to all of the changes the provision of services, which are free of needed. It is therefore necessary to make provi- charge at the point of use, should guarantee all sion for external actions that are likely to have a citizens equal access to health care. similar or even greater impact on health. • Sharing the financial risk. The financial system Health system reforms are being implemented should request contributions from all citizens to throughout the world. In the last ten years, the the health care system according to their indi- governments of many countries have attempt- vidual means and not in relation to the health ed to radically modify the basic principles of risks they are exposed to or the services they are their systems. In addition, the INHS has gone provided with. through a similar process of reform. The 1998- 2000 Italian National Health Plan (INHP) is the Health systems based on the above-mentioned mainstay of this process together with Italian principles aim to ensure greater social equity and Law No. 419 of 30 November 1998 and the better health expenditure control. The Italian Legislative Decree No. 229 of 19 June 1999. health care system has significantly contributed to improving the health conditions of the population. Many health indicators place Italy among 3. IMPROVING REGIONAL AND LOCAL the most successful countries worldwide, even ACCOUNTABILITY ahead of similar countries which allocate much higher budgets to health care. In fact, with ref- A health care system at the threshold of the erence to the OECD countries, the percentage third millennium can neither look back Nationwide solidarity agreement - 231

towards the models of the 1970s, nor simply • With the citizens accept the 1990s transition phase as final. On the contrary, it has to be further developed by Health promotion should be based on the seeking collaboration at the various different awareness and responsibility of people towards levels of accountability in order to create a their own physical, psychological and social new system which is suitable both nationally health, as well as towards their duties and and locally. rights. Furthermore, the citizens must be able At the national level, such a system must guar- to access bodies and institutions in charge of antee equal health care levels throughout the health management at the local level. country and to the entire population by means of accredited health services with uniform • With health professionals structural and organizational criteria. At the local level, Regional Authorities and One of the most relevant goals pursued is the Local Health Agencies must improve their improvement of human and professional accountability procedures concerning the plan- resources within the National Health Service. ning, production and provision of health care Health professionals are the key elements of services. the health care system because they are One of the main priorities is, therefore, to responsible for the performance and function- improve the regionalization (decentralization) ing of the services, for the effectiveness of the and managerial processes by basing the provi- actions undertaken and for the satisfaction of sion of health services on collaboration among the citizens. The humanization of the patient- the different INHS levels as well as between the doctor and citizen-INHS relationship is an INHS and other institutions and social partners important step in the solidarity agreement for involved. health. Commitment towards this priority must be considered an ethical investment which improves the quality of therapeutic 4. AN AGREEMENT FOR HEALTH interventions and strengthens their effectiveness. The ever-changing and complex social pattern prompted the establishment of a solidarity • With other health related sectors and agreement for health to be initiated and imple- institutions mented at the national level by the institutions operating in the field of health promotion. This Research into health determinants has high- process should also include the contribution of lighted the critical role of economic and social the citizens themselves, health professionals, factors which do not fall within and cannot be institutions, volunteers, non-profit and profit- controlled by the health service system’s sphere making health service providers, communica- of influence. Actions undertaken on such deter- tion channels and bodies as well as the Euro- minants require intersectoral coordination at pean Union and international community. The the governmental, regional and local levels so results achieved in the health field cannot only that they can be implemented as common be attributed to the technical quality of the ser- strategies. vices provided, because they are deep-rooted Health care is one of the highest priorities in the accountability of the different partners which should be pursued by all of the institu- concerned as well as in their capacity to col- tions whose activities have an impact on the laborate. These principles are the cornerstone population’s lifestyle, even if the former do not of the Italian National Health Plan (see para- have direct competencies within the health graph 5). field. 232 - Nationwide solidarity agreement

• With volunteers 5. THE ITALIAN NATIONAL HEALTH PLAN (INHP): PRINCIPLES AND PRIORITIES Volunteers and non-governmental organizations are the linchpin of a new solidarity agree- The 1998-2000 INHP, which was enforced by ment, both for the ethical principles they Presidential Decree of 23 July 1998 (S.O.G.U. embody and the vital roles they play in the 10 December 1998, No. 228) pursues the pri- humanization of service provision. Furthermore, mary goal of protecting and promoting health. they bear in mind the needs of the less well-off This goal requires that responsibilities be taken and provide a major contribution to the quality not only at the individual but also at the com- of care assessment. munity level. This would also bring about strategic changes aimed at devising intersec- • With health service providers toral health-promoting policies. The 1998-2000 INHP pursues the nine priorities The protection of the citizens’ rights with qual- described below. ified and timely health services not only entails responsibility for public competent bodies in 5.1 Strengthening the health service users’ ensuring such services, but also defines the decision-making autonomy limits within which the public and private sectors should develop. Non-profit and profit- The ability of users to be aware of and have a making health service producers play a signifi- choice between different diagnostic and thera- cant role in the field of health and should, peutic options must be one of the most distinc- therefore contribute towards setting up strate- tive features of the INHS-citizens relationship, gies and objectives for health protection and stemming from the improvement of informa- promotion. tion systems. Full completion of the transition from a paternalistic to a democratic concept of health care is still hampered by both health pro- • With the communication sector fessionals and users. In order to overcome this situation, basic and in-house training for per- Communication plays an important role in dis- sonnel should provide adequate knowledge seminating scientific information and recom- and expertise on issues regarding: mendations on the adoption of healthy • clinical epidemiology aimed at enabling lifestyles and attitudes. It also determines to health personnel to rationally explain the same extent the expectations and needs related effects of the different diagnostic-therapeutic to health and health services. The attention options to their users; given to the health field by mass media through • communication skills and sociology targeted daily news and the scientific dissemination at the acknowledgement of and respect for dif- channels calls for a strong commitment by ferent cultural identities in the field of health communication operators to provide balanced, care and disease; objective and comprehensive information on • economics, aimed at boosting awareness of health promotion and protection. the economic impact of health decisions and the need for funding which allows for the ful- • With the international community filment of the service users’ expectations; • ethics in relation to the health professional- Last but not least, the Italian health strategy patient relationship, aimed at promoting basic must fully support effective collaborations and professional ethical principles and the human- synergies at the international level (see Chap- ization of services. ter I). Nationwide solidarity agreement - 233

User’s decision-making capacity regarding their 5.5 Combating major diseases health depends on the greater ability of health professionals to provide information which is The INHP identifies the circumstances which both clear and accessible to all. However, any affect the population and cause death, disease enhancement of user’s decision-making power and disability. Consequently, it places high pri- is thwarted by the very nature of the informa- ority on the fight against the underlying cir- tion specifically relating to such highly special- cumstances that have a negative impact on the ized sectors in which these professionals oper- health of the population through primary and ate. secondary prevention measures and by improving the effectiveness of health care pro- 5.2 Promoting an appropriate use of health grammes. care services 5.6 Helping patients to actively cope with Given the variety of health care services, there chronicity are other relevant problems which should be addressed, such as the need for a more appro- The ever increasing number of ill and non-self- priate use of resources and the presence of sufficient people, particularly among the elder- inequalities in accessing and using health ser- ly, presents the need to help them to cope with vices. To this end, the 1998-2000 INHP aims to their conditions and, in the process, to develop set guidelines based on scientific evidence, their potential to continue to be functionally draw up professional agreements and guaran- independent and socially active. In order to deal tee transparency in its relations with the pub- with chronic health conditions, it should be a lic. health priority to ensure continuity of care and pay particular attention to all the factors which 5.3 Overcoming health-related inequalities can improve the quality of life of the chronically-ill and the non-self-sufficient. In particular, it In order to address inequalities in health condi- is vital to provide both home care to these peo- tions, health oriented policies should improve ple and the necessary support to their families the attitudes of both people and communities in order to allow them to be treated at home towards healthy lifestyles, ensure easier access for as long as possible. to health care systems and encourage positive cultural and economic changes. Once these 5.7 Finalising the social-health integration foundations are well established, the goals pur- process sued by the INHP will be easily achieved. The growing complexity of both health and 5.4 Fostering healthy lifestyles and atti- social demands requires the provision of inte- tudes grated services. However, professional integration alone cannot improve the quality and Disease prevention and health protection for effectiveness of such services; it needs to be healthy people are based on the identifica- grounded in institutional and managerial con- tion and control of exogenous factors and ditions aimed at coordinating the actions personal behaviours which may have an undertaken in the different service delivery impact on the onset of diseases, as well as of sectors. To this aim, regional governments the environmental factors that are detrimen- should lay the foundations for institutional tal to health. The 1998-2000 INHP aims at collaboration within territorial areas, starting promoting healthy lifestyles among the pop- at the district level, by formulating social- ulation. health unified plans at both the regional and 234 - Nationwide solidarity agreement

sub-regional level; moreover, it is necessary to 5.9 Investing in human resources and sys- differentiate between funds allocated to tem quality social services and those targeted to health services. The development of area-related The effectiveness of prevention, treatment and plans, especially in the field of highly integrat- rehabilitation-targeted investments stems main- ed social-health services, should foster the ly from the quality of the relationships between optimal use of resources, accountability and INHS professionals and INHS users. Health pro- collaboration. fessionals face major obstacles and resistance when they concentrate on the individual aspects 5.8 Promoting research of a problem, without any regard for a more global approach. For this reason, the INHP The goals outlined by the 1998-2000 INHP are should aim to ensure the conditions which serve peculiar for their innovative objectives as well as as a basis for the humanization and effective- for the organizational structure and the opera- ness of interventions. However, this requires a tional models provided for. The development of radical change in attitude, beginning with an an effective research strategy targeted at pro- acceptance of the ethical principles of health viding scientific soundness to health policies, care. Health professionals undergoing this tran- planning measures to be implemented and at sition must be supported by an effective dis- organising clinical and health care practice, rep- semination of information pertaining to the resent the necessary conditions for pursuing new system, in addition to continuous training such goals and for assessing the effectiveness facilities, intersectoral collaboration and devel- of any measures undertaken. opment of appropriate managerial skills. CHAPTER XIII

PRIORITY OBJECTIVES FOR HEALTH

CONTENTS 1. PROMOTING HEALTH-CONDUCIVE BEHAVIOURS AND LIFESTYLES 242 1.1 Nutrition ...... 242 1.2 Smoking ...... 242 1.3 Alcohol ...... 243 1.4 Physical activity ...... 243 2. COMBATING THE MAIN PATHOLOGIES ...... 244 2.1 Cardiac and cerebrovascular diseases ...... 244 2.2 Cancer ...... 244 2.3 Communicable diseases ...... 245 2.4 Injuries and occupational diseases ...... 246 2.5 Other socially relevant problems ...... 248 3. IMPROVING THE ENVIRONMENT ...... 248 3.1 Air ...... 249 3.2 Water ...... 249 3.3 Food ...... 250 3.4 Radiation ...... 250 3.5 Waste ...... 253 4. IMPROVING THE PROTECTION OF VULNERABLE GROUPS ...... 253 4.1 Efficient health-care services to the most vulnerable ...... 253 4.2 Immigrants ...... 254 4.3 Drug Users ...... 254 4.4 People with mental health problems ...... 255 4.5 Life-time care and health ...... 256 5. STEERING THE ITALIAN HEALTH SYSTEM TOWARDS THE EUROPEAN UNION ...... 258 5.1 Transplants ...... 258 5.2 Rehabilitation ...... 258 5.3 Technological innovation ...... 259 5.4 Monitoring rare diseases ...... 260 5.5 Self-sufficiency of blood and haemo-derivatives...... 260 5.6 Veterinary medicine in public health ...... 261 5.7 Health information system ...... 262 236 - Priority objectives for health

The Italian National Health Plan aims to: more general terms, other objectives are • Promote healthy lifestyles and behaviours; defined more precisely, with clear reference to • Combat major diseases; the specific quantitative indicators which must • Improve the environment; be met at the national level. • Strengthen protection for the most vulnerable Actions related to each objective represent a groups; preliminary indication of priority interventions • Make the Italian health system conform with to be included, according to the needs, within European Union standards. national, regional and local plans. In view of the intersectoral nature of these interventions, The Plan was launched in 1998 (Decree of the actions aiming to achieve the objectives set out President of the Italian Republic of 23 July 1998) in the Plan are often complementary to one and will continue well beyond the year 2000. another. The period 1998-2000 coincides with the first To allow for the assessment of actions under- stage of a process aimed at improving health taken, in addition to the specific indicators list- conditions by making it possible to fulfil medi- ed in Table XIII.1, two parameters should be um- and long-term goals. The health targets set verified for each of the objectives set at the in the INHP (Table XIII.1) are not intended to central, regional and local level. Such parame- meet all the needs of the country and other tar- ters refer to: gets, which represent large areas of interest, • guidelines issued and adopted and their dis- may fall within the jurisdiction of the regional semination; governments. • prevention and information campaigns con- Each health target has its own objectives and ducted, indicating the size of population suc- priority actions. Some objectives are defined in cessfully reached.

Table XIII.1: Italian National Health Plan: Targets

I. Health-conducive Behaviours and Lifestyles 1.1 Nutrition • To reduce energy from fat to no more than 30% of the daily intake of calories. • o reduce energy from saturated fat to no more than 10% of the daily intake of calories. • To increase energy from carbohydrates to at least 55% of the daily intake of calories. • To reduce energy from sugar to no more than 10% of the daily intake of calories. • To reduce daily salt intake to below 6 gr. • To reduce the prevalence of obesity. 1.2 Smoking • To reduce the number of smokers over the age of 14 to no more than 20% for men and/or women. • To reduce to zero the frequency of women who smoke during pregnancy. • To reduce the prevalence among smoker adolescents. • To reduce the average number of daily cigarettes smoked. 1.3 Alcohol • To reduce by 20% the prevalence of male and female drinkers consuming who consume more than 40 g and 20 g alcohol respectively, per day. • To reduce by 30% the prevalence of drinkers consuming alcohol between meals. 1.4 Physical Exercise • To increase by 10% the prevalence of individuals engaged in sporting activities during their spare time. • To increase by 10% the prevalence of elderly people engaged in sporting activities. Priority objectives for health - 237

Table XIII.1: Italian National Health Plan: Targets (continued)

II. Combating Major Diseases

2.1 Cardiovascular • To reduce by at least 10% mortality from ischaemic heart diseases. and Cerebrovascular • To reduce by at least 10% mortality from cerebrovascular diseases. Disease • To reduce inequalities in mortality between geographical areas and social groups. • To improve the quality of life of patients affected by heart and cerebrovascular diseases.

2.2 Cancers • To reduce mortality caused by malignant cancers by 10% for men and 5% for women. • To reduce mortality caused by lung cancer by 10% for men and stabilise it for women. • To reduce by 5% mortality caused by breast cancer. • To reduce by 10% mortality caused by stomach cancer. • To stabilise mortality caused by colon-rectal cancer. • To reduce by 10% mortality caused by cervical cancer. • To reduce inequalities in survival rates of people affected by malignant cancers. • To reduce social-class inequalities for incidence, survival and mortality caused by more common types of main cancer. • To improve the quality of life of cancer patients.

2.3 Infectious Diseases • To reach at least 95% vaccination coverage for children under 24-months including immigrants, agains polio, diphtheria, tetanus, measles, rubella, mumps, pertussis, and Haemophilus influenzae. • To achieve 75% vaccination coverage against influenza in populations over 64 years of age. • To monitor all unwanted effects of all vaccinations. • To eradicate poliovirus. • To monitor the effects of TBC treatments, ensuring that the pharmacological treatment is completed in at least 85% of the cases diagnosed. • To reduce by at least 25% the incidence of hospital infections.

2.4 Injuries and • To reduce by 20% mortality from road-accidents. occupational • To reduce by at least 20% mortality from road accidents involving 15-24 year olds. diseases • To reduce serious permanent disabilities due to road injuries. • To reduce the number of injuries at home, especially for high-risk groups. • To reduce by 10% occupational accidents. • To reduce occupational accidents in high-risk activities and reduce the incidence of the most severe cases. • To reduce the incidence of occupational diseases.

III. Improving the Environment

3.1 Air • To improve air quality.

3.2 Water • To increase availability of drinking water per inhabitant and the percentage of populations served by aque- ducts. • To increase wastewater treatment. • To reduce untreated wastewater.

3.3 Food • To reduce the incidence of food-borne diseases and enhance its surveillance system.

3.4 Radiation • To reduce concentration of indoor radon in both households and other indoor environments. 238 - Priority objectives for health

Table XIII.1: Italian National Health Plan: Targets (continued)

• To reduce the risk of exposure to ionising radiation from medical practices. • To regularly collect data concerning radioactive contamination following nuclear disasters. • To reduce risks related to exposure to UV-rays. • To prevent the effects of 50-Hz fields and of radiofrequency and microwave electromagnetic fields. • To provide proper information on radiation-related issues to the population.

3.5 Wastes • To enhance activities aimed at preventing negative health effects.

IV. Improving the Protection of Vulnerable Groups

4.1 Imigrants • To guarantee equal opportunities for public health assistance within the whole Italian territory in compliance with current regulations. • To extend vaccination coverage of the Italian population to include immigrants.

4.2 Drug abuse • To reduce mortality and morbidity rates related to drug-addiction and/or substance abuse. • To increase the percentage of users attending public health services and reduce the average addiction time span preceding such contact (early recruitment of users). • To increase the proportion of patients starting and completing rehabilitation treatments, thus recovering an acceptable level of social integration (especially with respect to reintroduction at work).

4.3 Mental Health • To improve living standards and the social integration of individuals affected by mental disease. • To reduce the incidence of suicides among risk groups.

4.4 Life Cycle and • To reduce perinatal and infant mortality to 8 per thousand in all Italian regions. Health • To prevent risk behaviours in pre-adolescents and adolescents, with reference to accidental serious injuries, self-injuries and drug addiction. • To prevent the causes of mental, sensorial and multiple disability. • To prevent cases of psychological and social discomfort during childhood and adolescence due to several causes, including abuse and ill-treatment. • To promote better informed family planning, protecting pregnancies at risk and providing adequate support to families. • To promote prevention and control of genetic disease. • To monitor health status in childhood, pre –adolescence and adolescence by focusing on the subject’s physical, psychological and relational features. • To promote and maintain self-sufficiency among the elderly. • To adopt supporting policies for families with elderly members needing home assistance. • To promote continuous or integrated assistance in favour of elderly people. • To promote and improve assistance to terminal patients.

V. Making the Italian Health System conform to European Union Standards

5.1 Transplants • To increase the number of transplants carried out in Italy and reduce the number of transplants carried out abroad. • To improve the donor network and increase the availability of organs suitable for transplanting. • To improve the security and quality of organs (and tissues) for transplant use. • To reduce mortality rates of patients on a transplant waiting list. • To increase survival and improve the quality of life of those who undergo transplantation. Priority objectives for health - 239

Table XIII.1: Italian National Health Plan: Targets (continued)

5.2 Rehabilitation • To guarantee continuity of care. • To guarantee effectiveness of treatments. • To tailor treatments to specific needs of patients.

5.3 Technological • To set priorities in developing new technologies. Innovation • To shut down obsolete structures and equipment and refurbish them properly. • To develop assessment procedures for technologies. • To improve the use of existing structures as well as managing processes to improve maintenance and management of biomedical equipment. • To involve staff in the introduction and management of new technologies. • To adapt equipment and technologies to safety standards. • To update diagnostic laboratory networks.

5.4 Control of rare • To guarantee prompt diagnosis and referral to specialised centres for treatment. Diseases • To foster prevention. • To support research.

5.5 Blood and Related • To increase the number of voluntary regular donors and donation index and decrease the number of occa- Components sional donors. • To rationalize use of transfusion and, if possible, make use of autologous blood.

5.6 Veterinary • To support quality assurance of Veterinary Public Health services and laboratories. Public Health • To develop the information system and integrate it at an international level. • To develop activities and interventions aimed at reducing risks. • To promote international cooperation in the field of Public Health Protection. • To develop training activities.

5.7 Health Information • To develop systems geared towards the aims of the national health system. System • To integrate the different health information systems and their synergy with those of the Italian Public Administration. • To enhance information systems locally and develop network connections. • To improve databases and data processing. • To value and disseminate the health information available.

The 1998-2000 INHP establishes a process to implementing projects at the regional level; transform the structure and improve the quali- invest in the improvement of human resources ty of the Health Service in such a way that it skills; implement effective organizational and remains consistent with its health objectives managerial strategies; adjust quantity and qual- and strategies. The effectiveness of the Plan ity standards, and guarantee uniform essential depends on the implementation of productive health care services at the national level. cooperation among institutional, professional These improvements must be incorporated into and community stakeholders, all of whom are the Health System’s operational and professional called upon to apply national objectives by patterns, as well as into its very organization. To 240 - Priority objectives for health

this end by means of the 1998-2000 National based upon the collaboration with regional gov- Health Plan, the Ministry of Health will guarantee ernments and other parties involved in the the further development of the planning action “health solidarity agreement”, taking stock of undertaken by providing a set of guidelines and pending issues which are likely to have an impact solutions aimed at achieving the health objectives. on the objective achievement process, i.e. the The Ministry will be responsible for supporting, possible approval of the social care bill in relation monitoring and assessing the implementation of to social-health integration and the implementa- health objectives and will serve as a guide in the tion of the decree that confers administrative uniform implementation of these new profes- tasks to regional and local governments. sional and managerial procedures in accordance The list in Table XIII.2 details the priorities by with the scientific standards set by the interna- which the Ministry of Health will further the tional community. Moreover, an ad hoc office will process already established by the 1998-2000 be established at the Health Planning Depart- INHP. This list of preliminary documents will be ment of the Ministry of Health to monitor the drafted during the three years covered by the implementation of the INHP in relation to the Plan. The relevant accountability centres, new procedures and supervise health care pro- though not explicitly indicated, have been vided and use of earmarked appropriations of the taken into account in developing the provisions National Health Fund. This Office will report to to be adopted. the Permanent Conference on the relationships The 1998-2000 INHP presents several cross-refer- between the Central Government and the Gov- ences to bioethics in all of its chapters, starting ernment of the 21 Regions and Autonomous with the basic principles, i.e. universality, quality of Provinces. The drawing up of guidelines will be access to services and shared costs, moving on to

Table XIII.2: Documents and provisions envisaged for the 1998-2000 term: priorities

General Guidelines Procedural Requirement • Access criteria for funds tied to the Plan’s objectives (sub-section 34 bis, art. 11, act 662/1996) (I) • Remuneration criteria for activities not envisaged by the per-service remuneration system (I) • Guidelines on authorisation and accreditation (A) • Implementation of the decree for the health care cost-sharing and exemption systems revision (P-I) • Health card (I) • Regulations on integrated health care in relation to primary health care levels (I) • Electromagnetic pollution (P) • Safety in health structures (P) • Health and environmental policies in the field of waste (P) • Health and energy policies (P) • Health and water supply (P) • Guidelines for prevention, hygiene and safety at workplace (A) • Guidelines for the authorisation and accrediting of structures providing highly integrated social and health services (A) • Minimum requirements for thermal waters medicine (P) • Rehabilitation guidelines (A) • Guidelines on care of terminal patients (A) • Guidelines on rheumatic diseases (A) • Guidelines on cardio-respiratory diseases (A) • Guidelines on the central nervous system diseases (A) • Guidelines on nephropathies (A) Priority objectives for health - 241

• Guidelines on diabetes (A) • Guidelines on blood (A) • Departmental organization guidelines (A) • Guidelines on appropriate use of drugs (A) • Guidelines on oncology screenings, including the diagnostic assessment of doubtful cases of tumours identified with screening programmes (A) • Guidelines on personnel training (A) • Guidelines on pregnancy, childbirth and healthy reproduction (A) • Guidelines for paediatric hospital care and family and community paediatrics (A) • Guidelines for congenital malformations and genetic diseases (A) • Guidelines on the re-organization of veterinary public health (A) Analytical documents • Inequalities in the health field (P) • Job-related health differences (P) • INHS financing, tax decentralization and equalisation system (P) • 1994-96 health care levels (P) • Control and contracts (P) • Purchase and price observatory (P) • Waiting lists (P) • Intramural professions (P) Clinical guidelines • Hypercolesteraemia early diagnosis and treatment (I) • Backache (I) • Pneumonia (I) • Bronchial asthma (I) • Peptic ulcer (I) • Physiological pregnancy (I) • Arterial hypertension (I) • Angina pectoris (I) • Breast cancer (I) • Cervix cancer (I) • Vaccination against influenza (I) • Antibiotic prophylaxis in surgery (I) • Pre-surgery diagnostics (I) • Day hospital for elective surgery (I) Targeted projects on: • Elderly people and non-self-sufficient people (I) • Mental health targeted project (I) • Drug-addiction targeted project (I) • Immigrants’ health targeted project (I) • Maternal and child health (I) • Food and nutrition (I) • AIDS (I)

I – means that understanding with the Permanent Conference on the relationships between the Central Government and the Governments of the 21 Regions and Autonomous Provinces is required before adoption; A – means that agreement with the above-mentioned Permanent Conference is required before adoption; P – means that opinion of the above-mentioned Permanent Conference is required before adoption. 242 - Priority objectives for health

its founding principles, i.e. dignity of the individ- consumption as well as increased physical ual, health protection, meeting primary needs, activity. solidarity towards the most vulnerable, effectiveness and appropriateness of interventions, equity 1.1 Nutrition and optimal resource allocation, and concluding with the mainstays of the INHP, i.e. patient auton- The improved nutritional status of the Italian omy, reducing inequalities, appropriate use of ser- population will essentially take place by pro- vices, and quality of care. It is clear that much moting the Mediterranean diet. Specific nutri- attention is paid to the bioethics of responsibility tional objectives, mainly concerning the control and solidarity. The latter encompasses the con- of food energy intake or of body weight, are cept of ”solidarity for health”, a bond uniting cit- listed under No. 1.1 in Table XIII.1. Actions to izens, workers, voluntary associations and the pursue these objectives include: mass media. It plays an advocacy role to better • Health education programmes which should protect the most vulnerable groups (immigrants, help the consumer to be aware of the importance drug abusers, patients with mental disorders, of nutrition and of appropriate dietary habits for minors, elderly people, terminal patients); it sets the prevention of diseases and for well being; the framework for organ transplants and blood • Improvement of consumer information on donations; it promotes rehabilitation and inte- nutritional quality of food products and verifi- grated home care, and lastly it confronts the long- cation of the accuracy of the information pro- standing and extremely thorny issue of rare dis- vided to consumers; eases. Moreover, the INHP is also based on the • Close monitoring of catering and food outlets ethics of quality of life, i.e. fighting against tobac- especially at schools, workplaces and communi- co, alcohol abuse and other “unhealthy” lifestyles ties and promoting healthy eating habits in (see also Chapter IX). these contexts. A more detailed description of the main targets of the INHP is reported below. 1.2 Smoking1

The main objective in this sector is to reduce 1. PROMOTING HEALTH-CONDUCIVE the number of smokers as well as the daily con- BEHAVIOURS AND LIFESTYLES sumption of cigarettes. Specific objectives are listed under No. 1.2 in Table XIII.1. This group of objectives includes improved In order to achieve these objectives, a number nutrition, reduced smoking and alcohol of on-going actions will be stepped up entailing

1 Main regulations in Italy in this sector include: • Law No. 584 of 11 November 1975, prohibiting smoking in specific public places; • Law No. 5 of 22 February 1983, regulating the ban on the advertising of national or foreign tobacco products; • Law 390/90 (single act of Law); • Law No. 480 of 29 December 1990 and Law No. 146 of 22 February 1994 (art. 23) concerning health warnings on individual packets of tobacco products (Directives No. 89/622/CEE and No. 92/41/CEE); • Ministerial Decree No. 425 of 30 November 1991, prohibiting direct and indirect television advertising of cigarettes and tobacco products (Television without frontiers Directive No. 89/522/CEE); • Law No. 142 of 19 February 1992 (art. 37) on tar content in tobacco products; • Law No. 50 of 18 January 1994, concerning the prohibited sale and purchase of illegal products; • D.P.C.M. 14 December 1995, prohibiting smoking in given places in the Public Administration and in facilities of public service providers; • Ratification of Directive No. 98/43/EC of 6 July 1998 in progress (on the ban of any direct and indirect adver- tisement of tobacco products). Priority objectives for health - 243

national, regional and local interventions focus- In order to meet these targets, a number of ing on: strategies and actions have been identified, • more strict enforcing of the smoking ban in including: public places and at work; • regulating the advertising of alcohol products • monitoring the enforcement of the advertis- and disseminating explicit warnings as to their ing ban of tobacco products (including indirect alcoholic content and harmful potential on advertising); health; • more clear visible warnings on individual cig- • initiatives to lower the alcohol content of arette packets; drinks and to step up quality control; • verifying the tar yield in cigarettes; • prevention information and education cam- • curbing the availability of low-cost tobacco paigns (at the National and Regional levels) products; aimed at curbing alcohol consumption among • educating and informing the general public specific population groups, such as pregnant on smoking-related dangers; women and young people and/or social con- • launching prevention campaigns among texts, such as schools and military barracks; young people under 16 years of age and • initiatives promoting alcohol rehabilitation women during pregnancy; with the participation of general practitioners, • promoting ‘stop smoking’ programmes, with to help heavy drinkers curb their drinking the participation of general practitioners, habits; • actions to monitor and regulate the distribu- A National technical and scientific Commit- tion and sale of alcoholic beverages in commu- tee has been operational in Italy since 1997 nity settings, particularly during sports and cul- with the mandate of developing legislative tural events, as well as in motorway service sta- proposals as well as primary and secondary tions; prevention programmes to reduce the physi- • tax incentives to curb alcohol consumption; cal damage caused by tobacco products. • more effective enforcement of regulations concerning the limits of alcohol concentrations 1.3 Alcohol in total blood when driving; • initiatives promoting a ban on the sale of In line with the WHO European Charter on alcoholic beverages to minors. Alcohol (December 1995), the Ministry of The implementation of the WHO European Health has set up a national Committee to pro- Charter on alcohol has resulted in the presen- mote and develop an action programme based tation of a number of bills to Parliament deal- on the WHO European Alcohol Action Plan ing with issues such as advertising, the quality (EAAP) strategies. This Committee includes rep- of alcoholic beverages, drinking and driving resentatives from many Ministries, (i.e. Social and taxation. At present, an overall bill is being Affairs, Foreign Affairs, Agriculture, Justice, prepared. Labour, Finance, Industry, Education and Trans- port), as well as experts and officers of the Min- 1.4 Physical activity istry of Health. The promotion of primary and secondary pre- The INHP has also laid down specific objectives vention, as well as of programmes linked to also for physical activity (see No. 1.4 in Table alcohol related problems and abuse, has been XIII.1). These objectives will be pursued through fully implemented in the 1998-2000 INHP and information and education campaigns as well its two main targets are indicated under No. 1.3 as through initiatives to facilitate the participa- in Table XIII.1. tion of different population groups in sport and other physical activities. 244 - Priority objectives for health

2. COMBATING THE MAIN PATHOLOGIES adoption of healthy lifestyles; the achievement of optimal levels of cholesterol in blood and Under Objective II, the 1998-2000 INHP con- blood pressure. firms its commitment to combat the most In order to monitor risk factors in the popula- important pathologies affecting the Italian pop- tion, health education campaigns and cam- ulation and causing the greatest number of paigns targeted at increasing awareness in deaths, disabilities or diseases which could be health professionals will provide an effective prevented by undertaking primary and/or sec- support to the above actions. ondary preventive actions. The following are the criteria used to identify b) Prevention actions for high-risk groups the key-intervention areas: These actions will aim to reduce prevalence risk – the relevance of the disease in terms of pre- behaviours and/or factors and to prevent com- mature deaths and preventable disease and/or plications among those already ill. disability; – the availability of an effective intervention or Actions will be aimed at: early diagnosis. – identifying high-risk individuals and providing them with special services; The key-areas are: – developing, disseminating and adopting guidelines for the care of patients suffering • Cardiac and cerebrovascular diseases; from hypertension and hypercholesterolemia; • Cancer providing rehabilitation programmes. • Communicable diseases; • Injuries and occupational diseases. 2.2 Cancer

In relation to the above areas, primary preven- In light of the trends recorded in the incidence, tive and early diagnostic interventions will be mortality and survival rates associated with can- singled out, whenever possible. An improve- cer and considering the interventions planned, ment in health care services will contribute sub- the aim of the 1998-2000 INHP is to achieve the stantially to curbing mortality rates and general goals listed under no. 2.2 in Table XIII.1. decreasing disability incidence rates, as well as Besides lifestyle-oriented primary preventive improving the quality of life. actions and prevention based on a healthy environment at work and at home, which the INHP 2.1 Cardiac and cerebrovascular diseases Health Targets I and III addressed (Table XIII.1), there are a set of actions which will be includ- The 1998-2000 INHP will pursue the goals listed in both regional plans and Local Health ed under No. 2.1 in Table XIII.1 Agency Plans. These are: To achieve these goals, the Plan makes provision for conducting the following specific a) Early diagnostic interventions actions which entail Regional and Local Health Agency interventions focusing on: These include screening campaigns for early diagnosis and periodic monitoring of risk fac- a) Prevention-promoting interventions which tors. In particular, early diagnosis programmes target the general population targeted at breast cancer, cervical cancer and, for some population groups, cancer of the In particular, these will focus on the benefits digestive system (above all colon rectal cancer) deriving from reducing smoking prevalence; the have proven to be effective. Priority objectives for health - 245

Consequently, the following actions will be car- 2.3 Communicable diseases ried out: – screening for breast cancer every two years Communicable diseases remain a major health for women in the 50-69 age-group; problem, in spite of the many effective preven- – screening by pap smear every three years for tive programmes and treatment protocols. women in the 25-64 age-group for the early There are many factors contributing to this sit- diagnosis of cancer of the uterine cervix; uation among which the following are the most – early diagnosis of familial invasive and pre- important: invasive cancer in high-risk people for genetic – the failure to appropriately adopt preventive reasons, limited to cancers for which an early measures which have proven to be effective, diagnosis has proven to be effective in modify- i.e. for some hospital infections or diseases, ing the natural course of the disease. whose onset can be prevented by vaccination; – the change in social and epidemiological con- The above screening programmes will monitor ditions bringing back diseases which were and assess the way they are used by the target almost eradicated, such as tuberculosis; population groups, paying special attention to – the onset of new communicable diseases and the less privileged and less educated individuals the growth of particularly aggressive or antibi- in these groups. They will also: otic-resistant strains. – develop guidelines for the diagnosis of suspected cases as well as for the timely treatment The 1998-2000 INHP has identified the follow- of confirmed cases; ing four priorities: – design a quality control system for the early • Prevention of HIV/AIDS; diagnosis programmes. • Prevention of hospital infections; • Prevention and treatment of TB; b) Life-quality improving interventions • Prevention of diseases for which vaccination is effective both with respect to risk and cost-ben- These programmes will be designed to improve efit. the quality of life of cancer patients with particular concern for the prevention of complica- 2.3.1 HIV infections and AIDS tions, rehabilitation processes and compassionate care. They will be backed up by the follow- The 1998-2000 INHP Project gives special ing actions: attention to prevention as a priority area. Since – developing, disseminating and adopting the onset of the AIDS/HIV epidemic and in guidelines for the treatment of terminal recognition of the fact that to date there is no patients; vaccine and no effective treatment, prevention – initiating appropriate rehabilitative pro- is considered a prerequisite for controlling the grammes as well as programmes for palliative spread of HIV. An ad hoc targeted Project is care and pain control; being finalised by the National Committee for – promoting the expanded use of home care the fight against AIDS and other communicable services which foster the involvement of the diseases. Great significance is attached to the patient’s family and social network. focus on preventive actions undertaken by public institutions involved in the fight against Finally, there is a need to promote the recording AIDS. Details are provided for the different of cancer incidence through the network of fields in which prevention has always been at Cancer Registers and to publish estimates of the forefront. With regard to information in incidence, prevalence and survival rates for the particular, the Project will continue to develop entire Italian population. the information-educational initiative already 246 - Priority objectives for health

started in order to ensure continuity, while tar- comprehensive vaccination programmes; geting not only the general public, but also improvement of integrated surveillance sys- those sectors which have either been excluded tems, including laboratory-surveillance and from the previous five information campaigns, rapid alert systems; or only marginally involved. • implement of surveillance programmes for Because the interventions provided for in Act antibiotic resistance, with specific reference to No. 135/1990 concerning the upgrading of human tuberculosis, and the adoption of policies hospital facilities have not yet been uniformly concerning the correct antibiotic use which can carried out throughout Italy, it is not surprising prevent the development of antibiotic resistance; that the epidemiological data available indicate • surveillance of food-borne diseases and that day-hospital, outpatient clinic and home zoonoses; and care services need to be further expanded. At • establish in each hospital a programme for the same time, it is evident that the network of the surveillance, prevention and control of hos- care facilities for communicable diseases pital infections, involving both patients and should be upgraded to take into account the health care professionals. The existence of such spreading of other communicable diseases. It a programme will be a prerequisite for hospitals will be up to each individual regional and requesting accreditation. A Committee vested provincial government to define, on the basis with the responsibility of controlling hospital of their specific needs, the areas to be upgrad- infections will need to be set up; specific man- ed and the extent of the upgrading. As for agerial responsibilities will be assigned to quali- research, the draft Project provides details on fied experts and intervention policies and writ- how to achieve the targets of this sector. To this ten protocols will need to be defined. end, it defines priorities and objectives which in A new Italian National Health Plan for paedi- part are common to the AIDS Research Project atric vaccinations has recently been approved launched by the National Institute of Health. by Ministerial Decree. As far as treatment is concerned, the emphasis is on improving procedures regulating experi- 2.4 Injuries and occupational diseases mentation and guidelines for treatment. This Project also addresses problems which HIV- Injuries and occupational diseases are a priority positive individuals must face and highlights the area in the field of public health because of the role of voluntary organizations. Particular atten- socio-economic-health burden they impose and tion is paid to the spreading of HIV-infection the impact they have on the quality of life of among inmates, the safeguarding of the rights the individual concerned. of individuals with HIV and the psychological and psychiatric aspects of HIV/AIDS. 2.4.1 Road Accidents

2.3.2 Other infectious diseases The INHP pursues the goals listed under No. 2.4 in Table XIII.1. The objectives adopted by the 1998-2000 INHP In addition to the lifestyles-oriented actions, as for infectious diseases other than HIV-AIDS are discussed in section 2.1, the INHP identifies the listed under No. 2.3 in Table XIII.1. following priority interventions: In order to achieve the above-mentioned objec- – increasing the use of helmets among motor- tives, the following interventions will be carried cyclists out: – improving safety standards in cars and pro- • Provide information to the population and viding education on the correct use of safety health professionals on the need to prevent devices (e.g. seatbelts, airbags and car seats for infectious diseases and on the importance of children); Priority objectives for health - 247

– upgrading road conditions (e.g. road signs, quite remarkable. However, in Italy the number lighting and traffic flows) in high-risk areas; of accidents at work remains high. – fostering safe driving through campaigns The 1998-2000 INHP pursues the goals listed aimed at respecting speed limits and drastically under No. 2.4 in Table XIII.1. reducing drunk driving, especially at night or in Intervention strategies aimed at improving the the evening; situation will give priority to: – improving public transportation. – strengthening and coordination of all preventive and monitoring activities carried out by the 2.4.2 Household Accidents relevant institutional bodies concerned; – full implementation of legislative decree Household accidents are a major concern and 626/94 on safety at work and its successive most of them are avoidable. People tend to amendments, as well as the immediate view the workplace, cars and any other means enforcement of all provisions laid down in the of transportation as the most likely source of above decree; accidents. However, the high percentage of – promotion of initiatives which target informa- household accidents should make people tion awareness, training and permanent educa- realise that the home can be regarded as a safe tion of all people concerned with prevention place only if spaces and objects are used cor- activities; rectly. – monitoring the quality and effectiveness of Accidents involving the elderly, especially in the preventive actions undertaken; institutions, require special attention. – development of a prevention-oriented epi- The 1998-2000 INHP pursues the goals listed demiological surveillance system (with particu- under No. 2.4 in Table XIII.1. lar reference to how work is organized). These When developing action programmes, the fol- systems should allow for the monitoring of lowing interventions will be given priority: accidents and the identification of their causes • upgrading safety in the household in terms of and mechanisms. its technical and electrical characteristics, as Regional governments and the relevant INHS well as in terms of furnishings and toy safety local units should undertake specific actions requirements; regarding the “Major Works” which are sched- • establishing intersectoral programmes which uled to take place in the INHP three-year peri- support the adaptation of household spaces to od, e.g. high speed trains and public works for best accommodate the needs of disabled and the Jubilee. They will establish an appropriate impaired individuals; monitoring system to record accidents and the • campaigning to increase the awareness of the preventive initiatives undertaken. population on household risks with special attention to high-risk groups; 2.4.4 Occupational Diseases • setting up an accident epidemiological monitoring system and identifying appropriate indi- To achieve the goal of reducing the number of cators for household accidents. occupational diseases and work-related diseases, the 1998-2000 INHP plans to carry out 2.4.3 Accidents in the workplace the following specific actions which entail Regional and Local Health Agency interventions Health and well-being at work are vital to focusing on: ensure the development of safe, productive and – strengthening and rationalizing training activ- competitive working conditions. These are well- ities designed for personnel concerned with established concepts in all industrialized coun- supervision and monitoring responsibilities; tries, and the efforts to achieve them have been – providing workers with relevant information; 248 - Priority objectives for health

– monitoring appropriate indicators and estab- – diseases of the digestive system, especially lishing an effective occupational epidemiologi- chronic diseases and in particular viral hepatitis. cal network; For the above diseases, the INHP will develop – pursuing compliance with the new prevention and disseminate ad hoc guidelines. and safety norms laid down in recent legisla- In the field of socially-relevant problems, special tion; consideration is given to individuals living with – prosecuting violators; some form of permanent disability, which often – promoting interventions directed at improv- is a serious limitation to their functional inde- ing the quality and accuracy of data regarding pendence (see Law No. 104 of 5.2.199 and occupational diseases and developing studies Law No. 423 of 27.10.1993). Since they run the on work-related problems. risk of clinical deterioration exacerbating their disability, they may require second and third 2.5 Other socially relevant problems level preventive interventions.

There are several other problems, which must be regarded as socially-relevant diseases. 3. IMPROVING THE ENVIRONMENT In some cases, provisions and guidelines already exist or are being drawn up, and address each All pollutants within the ecosystem interact sector for which they clearly set goals to be with living organisms. Consequently, health achieved, actions to be undertaken and organi- protection must take stock of and assess envi- zational patterns to be implemented. In partic- ronmental determinants. In particular, it should ular they concern: be concerned with the quality of air, water, – diabetes mellitus, a pathology for which the food and the environment as a whole. INHP is committed to provide a better level of Environmental issues attract the participation of care and monitoring, also in light of the existing many people and thus require a multisectoral regulations in the field of prevention and treat- approach. Consequently, we are confronted ment (Law 115/1987); with medium- and long-range activities and – cystic fibrosis (preventive and treatment skills and resources, which are not and cannot actions, Law 548/1993), inborn errors of be limited to the health sector. It is appropriate metabolism and adult celiac disease (integrated that the INHP prioritises activities aimed at health care, Ministerial Decree 1 July 1982). monitoring the environment with regard to There are other pathologies, which are causes high-risk situations and to the most vulnerable of disability and deserve special attention: segments of the population. – chronic rheumatic diseases, especially the The complexity of the interventions needed and most severe types affecting the young and the knowledge available in Italy call for the adults; establishment of a network connecting all the – allergies, especially in children and which different stakeholders. A networking system affect the respiratory tract; would promote fruitful synergies and avoid any – respiratory disorders, with special reference to duplication of efforts. bronchial asthma and chronic bronchitis; Among other things, such a network would – CNS diseases, both in their acute and chron- allow, for an accurate assessment of the health ic-degenerative forms; risks related to the environment. In this respect, – nephropathies, especially those leading to it is essential to develop proper modelling sys- kidney failure with consequent hemodialysis or tems to assess the impact of pollutants on the peritoneal dialysis; ecosystem, document the presence and con- – dietary behavioural disorders, anorexia and centration of risk factors and identify both the bulimia; affected populations concerned and the dura- Priority objectives for health - 249

tion of exposure, as well as existing interactions affect health (see section XIII.1.2 for Smoking in order to assess the impact on health. This and section XIII.3.4 for Radiation). assessment process is necessary to identify In light of the above considerations, and whenever necessary, what actions (of an eco- although there is still some degree of difficulty nomic, judicial, administrative and technical in defining specific objectives, it is relevant to nature) need to be taken. On 18 June 1999, outline what actions have been prioritized in Italy was one of the signing countries of the order to improve air quality. London Declaration on “Environment and The following are priority initiatives to be Health” (Annex 8), which identifies a number undertaken in order to reduce air pollution in of actions and programmes to be implemented the 1998-2000 period: in partnership with other European countries. – regulating transport and limiting private transport in urban areas; 3.1 Air – implementing transport policies enhancing the use of alternative energy sources and re-ori- Urban air pollution from vehicular traffic, heat- enting commercial traffic towards rail or sea ing systems or industrial plants, is an important transport; risk factor for health. – increasing the use of three-way catalytic con- It has been calculated that urban air pollution vertors; plays a clear role in the etiology of lung cancer – campaigning to make people aware of the determining an excess risk of up to 33% for the need to rationalize the use of energy sources in residents of metropolitan areas, irrespective of transport and heating; smoking habits. However, there is uncertainty – developing technologies to reduce industrial, regarding the overall impact of air pollution on car exhaust and household emissions; cancer incidence. – closely monitoring the emission of organic The relationship between the concentration of volatile substances in the surroundings of pollutants in the environment, as recorded in industrial plants, especially with regard to oil many parts of the country, and the increase in refineries and fuel depots; and morbidity and mortality rates, especially associ- – modernising household and collective heating ated with respiratory diseases, is well docu- systems in order to promote the use of less-pol- mented. In particular, environmental pollutants luting fuels. are associated with chronic respiratory diseases, worsen the symptoms of bronchial asthma, 3.2 Water increase the burden on health care services, including hospitalization, and increase the The health impact of the quality of water on number of deaths in persons already suffering health, can be broadly assessed using three from chronic diseases. Among the different air indicators: the availability of natural drinking pollutants, there are some which are a potential water resources which are suitable in terms of health risk and as such must be closely moni- quality, quantity and accessibility as drinking tored. This is the case of particulate matter, water; the size and effectiveness of the water especially that which is easily breathed-in due supply network; proper waste water manage- to its small particle size, sulphur dioxide, carbon ment and purifying systems. oxides, nitrogen oxides, benzene and asbestos. As in the case of air, information on water is Attention also must be paid to ozone, a photo- fragmentary and not always reliable. chemical pollutant, whose health impact has Only a part of the population can rely on prop- yet to be fully understood. erly recycled water. The large quantity of It is also important to understand that the qual- untreated water dumped directly into water- ity of air in closed environments can greatly ways, which is calculated as thousands of tons 250 - Priority objectives for health

of organic material, has an obvious impact on contamination, which may happen either dur- the ecosystem and on water quality. Ensuring ing production, packaging or storage. the availability of sufficient quantities of drink- To improve the hygienic quality of food, har- ing water is a goal still to be reached for signif- monization of monitoring activities that health icant parts of the Italian population, in particu- authorities carry out should be promoted, as lar citizens living on the islands and in the well as preventive self-monitoring process South. The presence of chemical or biological involving the whole food chain, from the pro- pollutants may cause illness. New scientific and ducer to the consumer. technical data are contributing to a more accu- The goal of reducing food-related diseases by rate identification of pollutants causing ill the year 2000 and simultaneously enhancing a health. permanent monitoring system has been set. In light of the above considerations, the follow- In the 1998-2000 period, priority will be given ing goals have been drawn up: to activities promoting the safety and integrity • availability of drinking water per inhabitant, of foodstuffs and the enhancement of their where necessary, shall be increased by the year overall quality by: 2000 and the percentage of the population – implementing and coordinating programmes connected to water networks will be increased. aimed at assessing the hygienic quality of food Special emphasis is placed on situations where products; water distribution and supply or its organolep- – monitoring the hygienic quality of products tic, chemical and biological peculiarities are used in public and collective catering; such that of water for human use availability is – collecting data regarding food pollution by severely limited. One way to deal with this is by radioactivity – now that over ten years have rationalizing and integrating networks, giving elapsed since the radioactive fallout of the priority to safeguarding quality and to conser- Chernobyl accident – with a view to determin- vation. ing a reference level, in the case of new poten- • activities aimed at the protection of waters tial accidents on a local, national and transna- from pollution by urban and industrial tional basis; processes will be further expanded by the year – implementing and assessing self-monitoring 2000. In particular, efforts will be taken to activities to include the whole food chain, ensure that pollutants (chemical contami- including catering services; nants, organic load, phosphorous, etc.) which – establishing surveillance systems for food- can be treated will be effectively eliminated borne diseases and carrying out proper epi- and that the quantity of polluted wastewater demiological investigations for each individual which is directly poured into waterways will case; be decreased. – campaigning to increase awareness in those involved in food production of the effects that 3.3 Food their actions or omissions could have on food quality; Every stage of food production, from farming – training and educating operators who direct- practices to industrial processing, distribution ly oversee the transformation and preparation and conservation and even to marketing, cook- of food, stuffs especially for collective catering. ing and delivery, contributes to the wholesome- ness of the food. 3.4 Radiation Any irregularity or inadequacy in any of the above stages in the process introduces the like- Exposure to radiation can trigger both short- lihood of health risks. Short-term problems usu- and long-term health problems. It is important ally occur in the case of microbiological food to differentiate between ionizing radiation Priority objectives for health - 251

(radioactive substances and radiation-emitting exposure to electrical, magnetic and electro- equipment) and non-ionizing radiation (electromagnetic fields, safeguarding health and reduc- magnetic fields) since they have different phys- ing the impact on the environment has become ical characteristics and interact differently with all the more timely. living organisms. In both cases, it is the long- In April 1992, the Italian Government prepared term effect on health – the onset of cancer – legislation on the exposure of the general pub- which is of greatest concern. lic to electrical and magnetic fields generated by high-voltage power lines, with particular ref- 3.4.1 Ionizing radiation erence to protection from acute (short-term) effects. Some regions (Piemonte, Lazio, Abruz- Besides promoting scientific research in the zo, Veneto, and Puglia) have passed regional field of ionizing radiation, the following are the Laws regarding exposure limits to protect the goals which will be pursued in the Italian con- general public from radio-frequencies. text: In 1995, the VII Standing Committee of the – reducing the risk of lung cancers from expo- Chamber of Deputies passed a resolution call- sure to radon, by decreasing the levels of radon ing on the Government to provide an organic at home and in other closed spaces. To this end, regulatory framework for protection against high-radon concentrations should be identified electromagnetic pollution and to amend exist- and the polluting sources found. Clear guide- ing regulations in accordance with the precau- lines and corrective measures should be devel- tionary principle in relation to the long-term oped, the population should be informed and effects arising from exposure to electrical, mag- training goals for all related professionals set; netic and electromagnetic fields. This resolution – decreasing the risk associated with exposure was followed by a motion put forward on 15 to ionizing radiation for individuals undergoing November 1996, once again calling on the radiodiagnostic clinical and nuclear medicine Government to take action in this matter. investigations, by eliminating unnecessary tests In order to ensure the protection of the gener- (health education campaigns can be of great al public from the possible risks arising from help in this context); implementing quality con- exposure to electrical, magnetic and electro- trol programmes and replacing obsolete pieces magnetic fields, the Italian Government has of equipment; also established an Interministerial working – collecting data on radioactive contamination party, co-ordinated by the Under-Secretaries of following nuclear accidents as also envisaged State for the Environment, Health and Com- for food. munications, to present to the Chamber a framework bills and has passed an Interminis- 3.4.2 Non-Ionizing Radiation terial Decree establishing radio frequency ceilings compatible with human health, in accor- In recent years, technological developments dance with Act No. 249 of 31 July 1997, which have brought about a significant increase in the introduces alongside exposure limits, more exposure of the general public and workers to restrictive protective measures to minimise electrical, magnetic and electromagnetic fields. exposure and prevent possible long-term In particular, the widespread use of cellular tele- effects. phones and telecommunication systems and The above-mentioned measures take account the expansion of the electrical energy distribu- of the fact that the health risks to be prevented tion network in order to meet energy demand include those (acute and deterministic in have brought about an increase in “electro- nature) for which it is possible to determine magnetic pollution”. In light of this, an organic threshold values from which exposure limits can regulatory framework for protection against be derived, and the long-term effects (stochas- 252 - Priority objectives for health

tic in nature) to be managed by the introduc- anism: the precautionary principle comes into tion of precautionary measures, warning values the definition of sufficient evidence in order to and quality objectives. make choices; the existence of margins of When trying to issue legislation regarding elec- uncertainty is not denied, but is taken into trical, magnetic and electromagnetic fields, a account, emphasising the fact that a cautious choice must be made between three main risk attitude is adopted in the choice of standards. assessment systems: In an approach of this type, the aim is to over- • the first system is based on protection against come situations in which uncertainty is denied acute (short-term) effects and leads to limits, by those who just want to take action and recommended by international standardisation exaggerated by those with an interest in delay- bodies; however this leaves lower-intensity ing any action taking. In a community in which exposure unregulated. Such an approach can- damage to health from certain types of envi- not fully resolve the conflicts arising when citi- ronmental exposure is suspected, the relation- zens call for preventive measures; ship of trust could be undermined if uncertain- • the second system, aimed at managing the ty was invoked in order to justify the lack of carcinogenic risk and long-term effects, does preventive actions. In the environmental sector, not consider a threshold mechanism but is “situations in which the scientific data are based on a relationship between exposure and insufficient to reach a definitive conclusion” are the probability of adverse consequences. The the rule rather than the exception, and yet a assumption underlying this model is that the decision must be made. Adopting this type of carcinogenicity of the fields should be proved approach means abandoning exposure limits beyond reasonable doubt, and that increasing intended as health measures in favour of the intensity of exposure corresponds to an adopting precautionary measures, warning val- increase in the risk of cancer. This assessment ues and quality objectives. In this connection, system has two main disadvantages. Firstly, it support is also provided by the European Parlia- implies a possible confusion between the con- ment resolution of 5 May 1994 (A3 – 0238/94). cept of a health limit, which must refer to an This resolution refers to the principle of preven- established phenomenon where the biological tive action laid down in article 130 of the Treaty mechanisms are known and the cut-off level of Rome. This principle, upon which there is are used to distinguish between two exposure general consensus, allows for strategies to be categories in some comparative epidemiologi- drawn up to combat exposure at a socially cal studies. The second problem is a practical acceptable cost, paying particular attention to one: all situations in which the limit is exceeded areas intended for young children and health- are assessed as abnormal, regardless of the related structures and also through research environment under examination and the and use of new technologies. degree by which the limit is exceeded; this is in In the regulatory measures for which provision contrast to the requirement to proceed on the has been made, the Italian Government has basis of priorities, as a consequence of the lim- adopted the third system of assessment and ited resources available; considers that the same should also be done at • the third assessment system is intended to the European Union level. deal with situations in which the causal link This is the main reason – although not the only between exposure and disease is not sufficient- one – why, when discussing the text of the ly established. The system is based on the need Council Recommendation on the limitation of to pay attention to partial results as well as exposure of the general public to electromag- accepting a margin of uncertainty and giving netic fields 0 Hz-300 GHz, at the European preference to the reproducibility of data over Council level, Italy did not accept the European understanding the underlying biological mech- Commission’s proposal. Priority objectives for health - 253

Therefore, during the European Council’s Meet- – upgrading the safety level of waste collection, ing of Health Ministers on 8 June 1999, in spite transport, storage, treatment and disposal of the majority political consensus on the Draft processes; Recommendation concerning the limitation of – improving a differentiated collection system exposure of the general public to electromag- for toxic and/or hazardous products by storage netic fields 0Hz-300 GHZ, Italy voted against it. in appropriate containers and activating mobile Italy also had reservations on a number of more collection services and collection points technical aspects of this Recommendation. throughout the nation; In this area, the INHP gives particular attention – enhancing environmental monitoring and to the following priority items: protection activities regarding the identification – reducing the risk associated with exposure to of illegal dumping as well as encouraging ultraviolet rays, by encouraging people to reporting; change their behaviours so as to include leisure – improving industrial waste disposal systems; activities and outdoor sports; promoting corporate and technological innova- – preventing the short-term effects generated tions to minimise waste production. by 50Hz fields, radio-frequency and micro-wave electromagnetic fields by enforcing regulations which set exposures limits. Protection against 4. IMPROVING THE PROTECTION OF VUL- potential long-term effects is based on pursu- NERABLE GROUPS ing “quality objectives” to be fulfilled over a certain interval of time and in a targeted man- 4.1 Efficient health-care services to the ner to accommodate various exposure scenar- most vulnerable ios; – providing the general public with clear and Individuals who have exceptional problems accurate information . quite often have complex needs and the health care system should respond to these needs in a 3.5 Waste consistent manner. One of the most vulnerable groups is the desti- The production and disposal of solid municipal tute who, because of their needs, are chroni- waste is one of the environmental challenges cally dependent on support. The socially disad- faced by most countries. Health risks arise vantaged and children, also have special needs. when waste collection, transport, storage treat- The disabled, whose income is below poverty ment and disposal are inadequate or non-exis- level, area high-risk category requiring a tent and fail to comply with strict health regu- planned, continuous and integrated approach. lations. Special attention must be paid also to the elder- In consideration of the extreme complexity of ly disabled as well as to the terminally-ill the issue, the difficulties encountered in identi- patients. fying what risks can be associated with each The 1998-2000 INHP promotes equity regard- agent’s toxicity or exposure and the problems ing the provision of services to the various pop- arising when setting up specific goals, the fol- ulation groups in need. In particular, the risk of lowing guidelines are recommended for dam- granting special access to given areas and age control: groups of users in need must be avoided, unless – reducing the amount of solid municipal such a privilege is justified by care needs and waste for disposal by promoting differentiated ethical considerations. This approach should municipal waste collection (the recovery of prevent those who can best represent and reusable materials and their transformation advocate their own interests from enjoying a into fuel); competitive advantage. 254 - Priority objectives for health

It is for this reason that the use of needs assess- worthy of close scrutiny and indeed protection. ment methods should be further promoted. At Apart from the conditions which threaten the the same time, global diagnoses should be health of all disadvantaged individuals and encouraged, thus preventing a sectoral which have a major impact on this group of the approach to interventions. Structure standards population (i.e. malnutrition, poor and unsafe must match process standards to guarantee housing, employment and societal interac- quality of care to safeguard the rights of the tions), there are other factors which weigh underprivileged. heavily on the health of immigrants. These stem To provide greater protection to the most vul- from the epidemiological patterns of illness in nerable groups in society, regional governments their countries of origin and are strongly inter- are required to focus on conditions of severe woven with cultural problems, such as the dif- marginalization in their jurisdiction and imple- ficulty immigrants encounter in communicating ment projects aimed at combating inequality of with and participating in the host community; access to health care. the psychological elements which take a toll on The establishment of health districts and their their well-being, i.e. as being removed from interprofessional integration are basic opera- their families, lacking strong psychological and tional conditions necessary for developing emotional support, fear that their migration multi-dimensional analyses and assessments. In expectations may come to nothing and, ulti- turn, different needs require appropriate mately, the discrimination they suffer with responses. Consequently, the tailoring of inter- regards access to services. ventions must take into account the lack of In Italy, access to health care is guaranteed to all self-sufficiency and the unavailability of immigrants at no cost in compliance with the reg- resources (economic, personal, family and com- ulations in force throughout the national territory. munity-related). According to INHP goals (see No. 4.1, Table The waste of resources resulting from avoidable XIII.1), the immigrant populations should be chronic conditions must be minimised by adopt- guaranteed the same vaccination coverage as ing efficient, cost-effective and compassionate the Italian population. interventions. This is why hospitalisation and In the 1998-2000 period, the following activities inpatient admittance can only be justified in addressed intersectoral policies aimed at safe- those instances where no other care facilities are guarding the health of migrant populations: adequate (day-hospitals, outpatient clinics and • set in place the necessary tools to recognize, intermediate and home care service). monitor and evaluate the health needs of immi- In this context, it becomes particularly impor- grants, also by enhancing collaboration with tant to make optimal use of available resources. the most qualified voluntary associations; Vulnerable groups specifically considered under • training health workers to focus on a multi- the INHP are: cultural approach to health protection; • immigrants; • organizing health care services so as to pro- • drug users; vide prompt access to and delivery of required • people with mental health problems; services, as well as to ensure that such delivery • newborn babies, children, adolescents, preg- be compatible with the cultural identity of the nant women and the elderly; respective immigrant populations. • terminally-ill patients. 4.3 Drug Users 4.2 Immigrants The 1998-2000 INHP as an improved under- Both epidemiological and socio-economic fac- standing of the phenomenon of drug addiction tors make the health conditions of immigrants focussed on a better identification of local Priority objectives for health - 255

problems and needs as well. It prioritises the different extents, contribute to the protection goals listed under No. 4.2 in Table XIII.1. of mental health: The actions to be accomplished in the three- a) promoting mental health throughout life year period of the Plan are: within the framework of preventive medicine • defining, experimenting with and introducing and health education programme; organizational procedures to be implemented b) enhancing primary and secondary prevention within the health care system to achieve a of mental disorders, with specific reference to higher degree of integration among all related risky behaviours, by implementing an “early public entities, as well as between the latter diagnosis” approach, especially among young and private non-profit and voluntary organiza- people, and establishing appropriate treatment tions; and preventive actions; • developing regional and local plans to combat c) promoting tertiary prevention, i.e. reducing drug abuse, involving existing social and health disabling consequences by recuperating the services; patient’s emotional ties as well as social fabric • introducing training programmes for man- through interventions aimed at tapping the agers and developing assessment tools to eval- individual’s resources and those of his/her orig- uate the quality of services provided; inal context; • optimising inter-institutional collaboration, d) safeguarding the mental health and the especially regarding primary prevention activi- quality of life of the patient’s family by improv- ties; ing the overall condition of families suffering • establishing and standardising surveillance from serious relational problems; systems and/or proper information flows con- e) curbing the number of suicides in popula- cerning the prevalence of different types of tions at high risk of specific mental pathologies consumption (with special reference to the and/or in given age-groups, such as adolescents newest and the most dangerous types of and the elderly. drugs). While designing activities to combat the occurrence of mental disorders, mental health ser- 4.4 People with mental health problems vices must improve preventive treatment and rehabilitation services for severe mental disor- As a follow-up to the INHP (see No. 4.3 in Table ders. These should result in reducing severe dis- XIII.1), a 1998-2000 targeted Project entitled abilities which can jeopardize the autonomy ”protecting mental health” is being finalised. and the use of the individual’s right of citizen- This new project will integrate a previous one ship, having chronic consequences such as by providing a clearer understanding of the social marginalisation. organizational aspects and, above all, by identi- To this end, it is necessary to: fying priority interventions on which to focus • take charge of and meet the health care service activities during the three-year term. A needs of all mentally-ill people or individuals major step forward is represented by the rele- requiring help; vance given to care services designed to cater • implement specific collaboration protocols for the needs of children, so as to set global between services to adolescents and adult ser- strategies for supporting mental health vices, to carry out preventive activities targeted throughout the lives of the target population. at identifying within the young population and In compliance with the INHP, the project identi- especially among adolescents, those people, fies the following five health goals which are to cultures and contexts most at risk. be achieved by setting in motion a complemen- The Project will also review the infrastructure tary and coordinated activity for all people and needs, throughout the National Health Ser- organizations which, in different ways and to vice. 256 - Priority objectives for health

4.5 Life time care and health between ad-hoc hospital facilities and community care services; The general goals for lifetime care and health – protecting women’s health through all stages under the 1998-2000 INHP are listed in Table of life by promoting specific approaches to XIII.1 under No. 4.4. issues associated with sexuality; encouraging In the life spans of most people, there are times awareness and responsible family planning val- when psycho-physical and relational changes ues; ensuring health care and support to create risk situations for health. These circum- women during pregnancy and childbirth, as stances require ad hoc preventive and health- well as preventing and treating maternal-fetal promoting actions. pathologies; The INHP gives special attention to four stages – providing health care services which enhance in life: reproduction, childhood, old age and the the human value of birth, ensure the safety of end of life. the mother and her newborn taking into account mothers’ wishes during such a signifi- 4.5.1 Childhood and Adolescence cant stage of her life; – initiating home care services for infants to In the 1998-2000 INHP, special attention is provide support for the socially impoverished given to the protection of health in women, segments of society; promoting breast feeding children and adolescents. The introduction of a and helping the family adjust to the newborn; Maternal and Child Care targeted Project is – devising and supporting programmes to pre- currently being developed. This project will vent cancer of the reproductive system in establish health goals such as protecting the women in collaboration with the Prevention mother and her newborn at birth, women’s Department. health in the course of their lifetime, as well as The establishment of the Maternal and Child health-promoting interventions targeted at Care Department is considered vital for prompt- pre-adolescents and adolescents (Table XIII.1, ing a fruitful synergy between community and No. 4.4). hospital activities. The existing interactions Reducing perinatal and infant mortality to a among all of the operational structures and in maximum of 8 per 1 000 in all Italian Regions particular between the Prevention Department by the year 2000 and eradicating the existing and the Health District would therefore be geographical differences remains the priority enhanced. goal. In addition, there are a number of prima- According to the draft Project, a child should be ry actions to be taken which are aimed at safe- hospitalized only when the treatment needed guarding the most vulnerable groups, while at cannot be efficiently delivered either at home the same time guaranteeing a uniformity of or in an outpatient clinic. In addition, the fol- care. These are: lowing conditions must be guaranteed: when – the provision of a paediatrician of each indi- hospitalized, a child should always be in the vidual’s choosing to be extended to all children; company of a parent or another person the – increasing the provision for and delivery of child feels happy with; minors should always be paediatric services to adolescents; hospitalized in wards for children and not for – meeting the social, health and care needs of adults; hospitals must not only be equipped minors, devoting special attention to adoles- with specific wards for children, they must also cents; provide playing and educational areas; continu- – guaranteeing an effective round-the-clock ity of care must be guaranteed by the hospital obstetric-gynaecological and paediatric emer- paediatric staff; an appropriate approach gency service, and promoting the integration should be devised as to the delivery of information on diagnostic procedures and treatment Priority objectives for health - 257

protocols to the child and his/her family in a more effective and integrated health, psychi- easy-to-understand way. atric and social service system, which citizens Regarding paediatric emergencies, each hospi- can refer to periodically to diagnose and identi- tal should be equipped with specific areas fy potential: where children can be referred for emergency • functional deficits; admissions. Moreover, Regional Governments • diseases which, if neglected, could develop should establish reference hospital facilities to into disabilities; manage emergency paediatric cases. These ref- • high risk behaviours associated with given erence facilities would ensure the provision of lifestyles or with environmental factors. hospital first aid and emergency care services To fulfil these goals, the INHS needs to: based on a close collaboration between the • guarantee access to medication and health Maternal and Child Care Department and the services aimed at improving hearing, mobility, Emergency Care Department. sight, chewing and continence functions, which are likely to deteriorate in the elderly; 4.5.2 Ageing • promote the early treatment of disabling diseases, so as to prevent the need for the elderly The progressive ageing of the population is a to resort to the treatment-rehabilitation cycle; major social and health issue for many coun- • deliver social health care services to the elder- tries. According to the 1998-2000 INHP (Table ly so as to reduce risk factors at an early stage XIII.1, no. 4.4), health policies for the elderly before they bring about the onset of ailments, people are being organised into an ad-hoc e.g. promote physical activity and a rational use targeted Project. These policies provide for of medication; and integrated interventions aimed at promoting • intensify preventive interventions in post- the prevention and recovery of physical dete- menopausal women. rioration and functional deficits, thus combat- Community services for the elderly should pro- ing the societal disadvantages that aging vide a wide range of different services including might generate. the establishment of ”Geriatric Assessment The INHP objectives and strategies include the Units” providing diagnoses and health care following: delivery; the provision of home care to specialist • promoting the maintenance and recovery of outpatients’ clinics, integrated with GP activities; self-sufficiency in the elderly (so-called “active the establishment of socio-health day centres; ageing”); the strengthening of tele-emergency and tele- • supplying integrated care alternatives to hospi- assistance; and health care residential facilities. tals, such as integrated home care, semi-residential care, and home hospitalisation in addition to 4.5.3 Caring for the terminally-ill preventing medicalization of social problems; • increasing sports activities by at least 10%; People suffering from irreversible pathologies • ensuring “flu” vaccine coverage in up to 75% for which there is no cure require special care of the population over 64 years of age; which targets pain control, infection prevention • cutting down on the number of household and treatment, physiotherapy and psycho- accidents in higher-risk categories; social support. Support must be provided to the • ensuring primary care needs; patient’s relatives as well, before and after the • assessing interventions and promoting a pro- patient’s death. A good level of care should gramme for “quality of care”. allow the patient to spend his/her last days at In order to achieve the goal of keeping old peo- home or, when this is not possible, to stay at ple fit, independent and self-sufficient for as well-equipped facilities to deal with the very long as possible, it is necessary to develop a special problems which can arise. 258 - Priority objectives for health

The 1998-2000 INHP is committed to improv- The need for transplants is bound to increase in ing the quality of care delivered to the termi- the next few years due to several factors, e.g. nally-ill and for this purpose, the following pri- the increase in operating surgical facilities and ority areas have been identified: the progressive extension of transplant clinical • improving home health and nursing care; indications. Furthermore, for cases where trans- • providing home-delivery of medication by plants represent the best cost/benefit alterna- means of the hospital pharmacies; tive to costly treatments (as in the case of kid- • enhancing compassionate care and pain relief ney transplants), the increase in transplant therapy; activity is also proved cost-effective. • granting more psycho-social support to the The situation will improve when the recently patient and his/her family; approved Law No. 19/1999 will have brought • promoting and coordinating voluntary care about its expected effects. These new regula- services to the terminally-ill; and tions make every Italian a donor unless • establishing residential homes (hospices), he/she refuses to be. They are based on many which are fully authorized and accredited. inputs including those raised by the scientific world, voluntary associations, patients waiting for transplants, and public opinion in 5. STEERING THE ITALIAN HEALTH SYSTEM general. TOWARDS THE EUROPEAN UNION In light of such considerations, the 1998-2000 INHP aims to further develop transplant activi- This sector deals with the 1998-2000 INHP ties and to improve the quality of interventions objectives targeted at those areas which, more (Table XIII.1, n. 5.1). than others, should match to the European To this end, the following are the targeted Union context in terms of programmes, organi- activities most likely to ensure the attainment of zation and management. the above mentioned goals: The gap with the rest of the European communi- • establish a National Transplant Register whose ty, mostly concerning specific areas of activity and role will be to foster information dissemination organizational processes, can only be bridged and knowledge of various national needs; through a deep cultural change. Greater stream- • reorganize intensive care centres and assess lining needs to be performed in such fields. their activity with regard to the identification of potential donors; 5.1 Transplants • identify and develop centres of excellence, especially with regard to rare transplants and The quality of organ transplant service in Italy is multi-organ transplants; similar to that of the most developed countries in • define acceptance criteria for waiting lists to per- the European Union. However, the number of mit greater uniformity throughout the country; transplants is still far from EU levels and cannot • implement information and awareness cam- properly meet lengthy waiting lists owing to the paigns targeted at both the population and shortage of donors (in spite of the increase health professionals to promote organ donation; recorded in the last five years, in 1996, the ratio and of donors/inhabitants was eleven to one million). • enhance paediatric transplants. In addition, there is an uneven distribution of organ removal and transplant activities through- 5.2 Rehabilitation out the country. Subsequently, many Italians pre- fer to resort to foreign health care services, some- The targets of the 1998-2000 INPH in the area of times also for those types of transplants for rehabilitation are reported under No. 5.2 in Table which Italian expertise is of very high quality. XIII.1. Priority objectives for health - 259

Rehabilitation requires multi-dimensional and • ensure the effectiveness of services delivered; multi-specialistic approaches. It requires the inte- • establish the level of ‘intensity’ of the health gration of different interventions which can be care services according to patients’ needs. achieved through enhanced therapeutic conti- To this end, it is appropriate to: nuity so that rehabilitation is started at an early • establish and classify the functions of the dif- stage, functional recovery is fostered and disabil- ferent public and private service providers; ity-compensating skills are developed. Moreover, • overhaul the rehabilitation sector with regard patients’ self-sufficiency with special reference to to intensive rehabilitation, both at the hospital the evolutionary phase, the elderly and patients and extra-hospital levels, as well as intermedi- affected with post-trauma neuro-pathologies ate extensive rehabilitation and long-term post- should be supported through the provision of a acute hospitalisation management. number of effective interventions. In parallel, regional plans will focus on further- Rehabilitation care will be based on facilities ing management and professional goals by: and services at different levels (district,local • carrying out professional changes and reorga- health Agency and so forth) with different ways nizing interventions based on the different of providing health care (hospital, outpatient, rehabilitation functions; residential and semi-residential). It will allow for • enabling the different accountability centres the assessment and diagnostic framing of to improve interventions; health care needs on the basis of evidence- • implementing the systematic monitoring of based therapeutic and rehabilitation pro- both intervention efficiency and effectiveness; grammes. • assessing the level of technical and techno- At the hospital level, rehabilitation will be logical suitability with measurable indicators; administered either in ad-hoc departments or • fostering functional integration among the through functional Recovery and Rehabilitation different operational units concerned, so as to Services. These should be connected to the dif- provide health care continuity from treatment ferent operational units, providing for long- through to rehabilitation; and term hospitalisation aimed at functional recov- • promoting professional and social integration ery and rehabilitation. As regards the latter, it is projects. already an integral part of the internal and operational organization of highly specialized 5.3 Technological innovation rehabilitation departments. The very nature of rehabilitation demands The 1998-2000 INHP aims to achieve the goals requires constant commitment. This commit- listed under No 5.3 in Table XIII.1. ment must be directed towards the integration Regional and Local Health plans shall focus on of the different types of interventions establish- the following priority actions: ing rehabilitation circuits targeted at providing • assess existing technologies in terms of equip- health care continuity and effectiveness. ment status and use; Advances in such integration will be made • further develop incentives to eliminate obso- through the establishment of systematic links lete equipment; between hospital and extra-hospital care, as • define co-financed regional programmes well as between health and social care. (involving State, Regional governments and The reorganization of rehabilitation activities Local Health Agencies) to be targeted at high should comply with the following general technology investment sectors on the basis of a objectives: needs assessment, in order to establish inter- • vouch for health care continuity, thus ensuring regional ad hoc reference centres; the systematic introduction of rehabilitation in • coordinate the promotion of applied research the “prevention, care and rehabilitation” circuit; project targeted at carrying out testing and tech- 260 - Priority objectives for health

nical and clinical assessments of new technolo- eases at the National Institute of Health in order gies both at the national and regional levels; to document the distribution and types of rare • provide full economic accountability of health diseases across the nation. care institutions (operating according to the Patient who are eligible for certain drug pre- ‘fee for service’ principle) for restructuring and scription, are exempt from paying fees. The reg- upgrading technical equipment. ulation lists 284 diseases and 47 groups of rare With specific reference to the network of diag- diseases for which health care services are pro- nostic laboratories, the 1998-2000 INHP aims to vided at no charge to the patient. Patients suf- foster their compliance with quality, effectiveness fering from rare diseases can avail themselves and productive efficiency objectives. To this pur- of all necessary services free of charge to diag- pose, the following goals are especially important: nose, treat and monitor their diseases and to • development of a network of laboratories on the prevent deterioration. basis of each laboratory’s specialization and type; • development of quality control programmes 5.5 Self-sufficiency of blood and haemo- targeted at these laboratories; and derivatives. • guarantee of cost-effectiveness. In accordance with the objectives contained in 5.4 Monitoring rare diseases the 1998-2000 INHP (see No. 5.5 in Table XIII.1), achieving self-sufficiency and blood Rare diseases can only be addressed with spe- safety are priority goals of the 1998-2000 cialised and constant care. Given their spe- National Blood and Plasma Plan and lie at the cialised nature, the services required can be very core of its activities. Every institutional provided only with a significant financial contri- body, at the national, regional, Local Health bution from the State. Dealing with rare dis- Agency and hospital levels, should adopt these eases also requires close coordination of all the goals to meet the Plan’s objectives. initiatives implemented in this field. Listed below are the Plan’s overall goals and The 1998-2000 INHP aims at the initiatives list- certain activities to be undertaken in order to ed in Table XIII.1, No 5.4. achieve them: Priority interventions in this area include: • identification and classification of the different 5.5.1 Self-sufficiency national reference service-providing centres • establish a new more effective information according to the type of disease to be treated, system; and the establishment of a network of hospitals • plan a coordinated response between the connected to such centres aimed at diagnosing central and regional governments, in compli- and treating of single (or groups of) rare diseases; ance with the provisions laid down in Decree • implementation of a national research pro- No. 308/97regarding setting of the country’s gramme targeted at enhancing prevention, requirements of blood, blood components and early diagnosis and health care, and at identify- products; ing new therapeutic approaches; • regulate blood transferral arrangements • development of interventions targeted at between regional governments and Local improving the quality of life of patients affect- Health Agencies; ed by rare diseases; • rationalize the production and distribution • development of information programmes tar- system. geted at patients with rare diseases as well as their families. 5.5.2 Streamlining the organizational model Surveillance activities will be centralized by • strengthen organizational management struc- establishing a National Register of Rare Dis- tures and technical scientific coordination bodies; Priority objectives for health - 261

• upgrade the infrastructure of the National Organization have led to and continually pro- Institute of Health so that it can better under- duce major changes in animal health and animal take the tasks entrusted to it; reproduction world. Market globalization entails • streamline and organize blood transfusion preventive and monitoring actions targeted at facilities by acting at the departmental organi- both animal health and at products of animal zational level; origin to be developed and managed in compli- • reorganize the emergency system; ance within the international marketplace. • coordinate the National Transfusion Service facil- Truly effective and efficient consumer and ani- ities as well as voluntary associations, so as to mal protection must be grounded on a new enable them to cope with ever-changing needs. functional integration of preventive and monitoring activities to be implemented at the local, 5.5.3 Transfusion safety national and community levels. Integration is a • standardize procedures; necessary preliminary step ensuring high quali- • activate and coordinate the surveillance sys- ty service of veterinary medicine in public tem; health, and Italy is today considered one of the • establish a national blood surveillance system; best models in this field. • ensure voluntary, regular and free blood By virtue of the integration of production and donation. distribution systems, health protection tasks can be performed only through service 5.5.4 S&T Development providers who are able to guarantee homoge- • develop new transfusion technologies; neous high quality levels of service. To this end, • design special research projects; accrediting veterinary medicine public health • arrange training schemes. laboratories and services, represents a very important step and must be implemented in 5.5.5 Quality, efficiency and cost-effectiveness compliance with quality standards and regula- of transfusion services tions. • ensure accreditation of transfusion facilities; To support these interventions, the information • establish a quality monitoring system; technology system in this field must be both • streamline transfusion procedures; upgraded and integrated at the National level. • activate monitoring systems targeting effi- This could also be considered as a preparatory ciency and effectiveness in transfusion centres. stage for the integration to be achieved at the EU level. 5.5.6 Social Policy applied to Transfusions For these reasons, the establishment of a • support the growth and development of the national veterinary epidemiological monitor- functions institutionally vested into voluntary ing system, as provided for by the 97/12/EC blood associations and federations; directive, cannot be postponed any further, as • ensure provision of blood and blood products it is necessary to provide a transparent and at no charge; reliable framework for ensuring hygienic and • strengthen facilities involved in the identifica- sanitary levels of food of animal origin as well tion of biological hazards; as the health of animal populations; further- • promote information and protection of citi- more, it would allow for the full implementa- zens. tion of the guidelines developed for the field of veterinary medicine in public health reorga- 5.6 Veterinary medicine in public health nization. As provided for by the new standards of the EU The implementation of a single market and the on consumer health protection, risk analysis international agreements within the World Trade will pave the way for the programming of risk 262 - Priority objectives for health

reduction/elimination measures, thus overcom- Decisions regarding the organization and ing the old approach that only provided for development of health services, as well as the infringement or damage assessments. programmes aimed at quality improvement, Within this framework, it is important to devel- must be grounded on a system of information op and set up programmed monitoring activi- concerning the results to be pursued and ties related to transmissible spongiform those already achieved, the resources that are encephalopathies (TSE), thus ensuring the cur- necessary to achieve the stated goals, and rent favourable health situation in Italy as those which have already been allocated and regards bovine spongiform encephalopathy. used. Due to the trade relations between non-EU Therefore, it is quite clear that the development Countries and the EU, effective protection of of an effective information system must lay its consumer ‘s health in the EU also depends on foundations on both flexibility and the coordi- the health situation in non-EU Countries. The nation of the numerous information systems Eastern European and Mediterranean coun- operating at the local, regional and central lev- tries are especially important within this els in the field of health, health services and framework and it is necessary to develop health service costs. cooperative actions in the field of veterinary On the basis of these considerations, the 1998- medicine in public health. 2000 INHP aims to restructure and redefine the Training initiatives are particularly strategic to Health Information System so as to improve its develop quality-oriented services. The assess- effectiveness and efficiency in relation to the ment of training requirements and needs in INHS management needs and its duties terms of permanent training initiatives targeted towards citizens in terms of information trans- at public sector veterinary surgeons is the parency (Table XIII.1, No. 5.7). responsibility of the parties which are to allo- The restructuring of the Health Information Sys- cate adequate resources to these training activ- tem will stem from the following general prin- ities. Priority will be given to a consistent and ciples: closer relationship between service require- • specification and definition of the different ments and University study plans, as well as to users’ information needs; increase in the number of training courses on • development of systems oriented towards the the implementation of Community regulations end results outcome of health services in terms and agreements with non-EU Countries (sce of health, quality of life and patients’ satisfac- also Table XIII.1, No. 5.6). tion; • integration among the different health infor- 5.7 Health information system mation systems and between these and the other information systems operating within the The Italian Health Information System (SIS - Sis- Public Administration (Municipal Registers, tema Informativo Sanitario) is meant to meet dif- National Social Security Institute and National ferent information needs relating to different Institute for Insurance against occupational stakeholders (citizens, professionals and man- Injuries), implementing a functionally inter- agers operating at different levels in the system). operability perspective; Citizens can fully enjoy their rights within the • enhancement of information systems at the health system. They can be made accountable local level and development of network con- for their own health only if duly provided with nections; reliable, accurate and clear information on the • development of adequate protection of con- services available, their functioning and their fidentiality and guarantees within the system; results. • adoption of protocols of agreement for data processing which could prove useful in meeting Priority objectives for health - 263

local needs and are compatible with central ber of families, continually bearing in mind the information needs; and health planning and assessment needs at the • enhancement and dissemination of the Health national and local levels. Information System’s wealth of information It is of the utmost importance that part of the The health objectives of the INHP imply a con- yearly survey specifically targeted at health and stant information need which can only be ful- the use of health services allows for the moni- filled through the integrated use of current toring of the Plan’s objectives which are most information flows, backed up by telecommuni- likely to be achieved within a year or a three- cations tools, specific monitoring systems and year term. Furthermore, it is necessary to population surveys. ensure that this targeted survey is adequately To this end, ISTAT’s family-oriented multi-pur- oriented towards the assessment of health indi- pose survey system should be further enhanced cators as well as towards the attitude, behav- through the integration of the information col- iour and service-use indicators, which could not lected as well as by interviewing a greater num- otherwise be measured. CHAPTER XIV

CHANGE-PROMOTING POLICIES AND STRATEGIES

CONTENTS

1. GUARANTEES PROVIDED BY THE ITALIAN NATIONAL HEALTH SERVICE ...... 266 1.1 Guiding principles ...... 266 1.2 Essential health care levels ...... 266 1.3 Structuring health care ...... 269 1.4 Determining the average budget per-capita ...... 270 1.5 Financing health care levels ...... 271 2. TOOLS TO GUARANTEE HEALTH CARE LEVELS ...... 271 2.1 Meeting protection objectives ...... 271 2.2 The financing of Regional Governments and Local Health Unit Agencies ...... 273 2.3 Remuneration for health service providers ...... 274 2.4 Accrediting of health sectors ...... 274 3. A NATIONAL QUALITY ASSURANCE PLAN ...... 275 4. SAFETY OF HEALTH FACILITIES ...... 275 5. INTEGRATION BETWEEN HEALTH CARE AND SOCIAL ASSISTENCE 276 5.1 Socio-health integration ...... 276 5.2 Integrated homecare ...... 277 5.3 District ...... 277 6. HUMAN RESOURCE MANAGEMENT ...... 278 6.1 Training ...... 279 7. RESEARCH, EXPERIMENTATION AND DEVELOPMENT ...... 280 266 - Change-promoting policies and strategies

1. GUARANTEES PROVIDED BY THE ITAL- – protection: according to which the health of IAN NATIONAL HEALTH SERVICE the individual must be protected before it is undermined; The process of ensuring health care and the – need: according to which those in need have standards of service guaranteed under the Ital- a right to health care and that available ian National Health Service (INHS) involves: resources must, as a priority, be allocated to the – Stating the principles which define the cover- promotion of activities aimed at meeting the age provided and guaranteed by the INHS for primary health care needs of the population; its citizens; – solidarity towards the most vulnerable: – Specifying tasks and activities organized with which demands resources to be allocated pri- respect to each type of service; marily to support groups of people, individuals – Specyfing guaranteed interventions and deliv- and certain diseases that are socially, clinically erable services together with criteria judging and epidemiologically important; the appropriateness of the use that citizens – effectiveness and appropriateness of make of the INHS’s services; interventions: according to which resources – Establishing the “budget (or quota) per capi- must be channelled for services whose effec- ta” to guarantee health care standards; tiveness is scientifically grounded and for indi- – Determining the overall INHS budget so that viduals that can benefit the most from them; it does not exceed available funds; – cost-effectiveness: which stresses that – Ensuring that tools to maintain health care when choosing among different supply pat- standards are devised and made operational. terns and types of activities, priority should be International experience has shown that setting given to solutions which can maximize the health care standards is indeed a very complex results, using equal resources; task because of its social and technical conse- – equity: which guarantees that no geographical quences as well as its ever-changing nature. In and economic barriers should prevent any indi- fact, it must take into consideration the scien- vidual from accessing the health care system and tific and technological progress which heavily that information gaps and behavioural differ- influences any evaluation of the effectiveness ences should be bridged to avoid health discrim- and appropriateness of services. Consequently, ination among individuals and groups of people. the 1998-2000 Italian National Health Plan is Equal access and availability of health care must only able to illustrate the principles and gener- be guaranteed in the light of equal needs. al criteria, while operational definitions relating to the different sectors of activity will need to 1.2 Essential health care levels be given detailed consideration in ad hoc guidelines. Essential health care levels are defined as the services and standards coverage which the 1.1 Guiding principles INHS guarantees to its citizens in the light of the nature of the targeted needs and of their The 1998-2000 INHP defines health care stan- effectiveness and appropriateness of use. The dards in accordance with the main principles on aim is to meet national needs to protect public which the Italian National Health Service is health within the limits of the available funding based. The principles relate to: (Art. 1, item 1, Legislative Decree No. 502/1992 and subsequent amendments and updates; – human dignity: according to which every INHP1994-1996). individual has equal dignity and equal rights In the 1998-2000 Italian National Health Plan, irrespective of his/her personal characteristics the health care levels define the scope of the and role in society; Change-promoting policies and strategies - 267

coverage which the INHS undertakes to provide specifying cost-allocation criteria – is essential uniformly to all of its citizens across the nation. for ensuring access to health care services in the Essential health care levels stand for services less prosperous and marginalized areas, while and standards that are necessary (because they at the same time safeguarding proper social satisfy the basic needs of promoting, maintain- care services. ing and restoring health in the population) and All citizens should receive health care services appropriate (both regarding the individual’s included in essential levels (Art. 50, Act No. specific health requirements and the ways in 450/1997 and Decree Law No. 124/1998) which services are provided). As such, they • at no cost at the point of use with respect to: should be delivered uniformly throughout the – instrument and laboratory diagnostics, as well nation and be guaranteed to everybody in full as other specialised services provided for in pro- recognition of the differences that characterize grammes for early diagnosis and mass preven- the distribution patterns of health care needs tion, carried out in accordance with the INHP, and health risks. regional health plans, or promoted or autho- In order to guarantee essential health care lev- rized by formal decisions of Regional and els, it is necessary to restructure the system so Provincial authorities; as to involve the different INHS sectors for – instrument and laboratory diagnostics, as well appropriate intervention. as other specialised care services aimed at pro- Greater commitment should be made in reallo- tecting public health, which are compulsory by cating resources: law or set as mandatory by local authorities fol- – from treatment to prevention; lowing epidemic outbreaks, and also medical – from the general population to risk-groups; investigations included under employment con- – from hospital-based to community-based tracts; care. – general medical and paediatric services cho- The reallocation of resources is to be achieved sen freely by the user; by developing programmes aimed at fostering – treatments administered during hospitalisa- widespread coordination among and within tion, including rehabilitation and long-term local health agencies. It should provide for the post-acute inpatient care; enhancement of outpatient hospitalization (as – services directly and closely related to elective an alternative to regular inpatient care); the hospitalisations, previously delivered by the development of residential and home rehabili- same facility, in compliance with Art. 1, item tation and long-term care (as an option to 18, Act No. 662 of 23 December 1996. acute care); the spreading of integrated care at • upon payment of a limited contribution for home (as an alternative to hospital-based care); the remaining services, which are not fully cov- the devising of selective periodic screening pro- ered by the INHS, in accordance with legislation grammes targeting high-risk-populations (as an now in force. The cost-sharing mechanism is alternative to diagnosis on demand at out- meant to make the user aware of the econom- patient clinics); reducing the use of instrumen- ic burden attached to service provision, but in tal diagnostics also with regard to the appropri- no way will it hamper access to health care.In atness of requests and, in particular, with compliance with the 1998-2000 Financial Plan- regard to expensive or in-series services; the ning Document, social equity goals require that strengthening of dental and eye care (which are the INHS provides health care uniformly by presently unsatisfactory) as well as undertaking implementing measures and undertaking any other reallocations specifically aimed at actions aimed at eliminating factors which adjusting supply at the local level. could turn social and economic differences into Achieving effective integration between social health inequalities and into unequal access to and health care services – and consequently health services. 268 - Change-promoting policies and strategies

Abolishing economic barriers which hamper Services not covered by the “average budget access to health services is not sufficient to per capita” include cosmetic surgery not per- guarantee access to those who have equal formed by way of treatment for injuries, dis- needs. Uniform access to the various services eases or congenital malformations, and medical throughout the nation is needed, regardless of services which, although prescribed by proper differences among social groups. Uniformity certification, do not belong to the category of implies the gradual elimination of any limita- services designed to protect collective health, tion, even implicit, in INHS coverage. Poor sup- despite being required by regulations. No cov- ply of services, the lack of information on avail- erage is provided also in the case of non- ability and access, and abnormally lengthy wait- mandatory vaccinations required for travelling ing times with respect to service needs are the abroad. most important factors hindering the attain- The above-mentioned criteria also exclude ment of true uniformity of care. forms of health care which despite meeting the In accordance with the guidelines setting ser- principle of clinical effectiveness, still fail to vice priorities and identifying management meet specific service needs. These are either objectives, regional governments and local grossly overestimated in terms of times, modes health agencies alike, are to develop proof delivery or quantity. The same applies to ser- grammes to reduce waiting times for hospitali- vices which can be replaced by others that are sations and access to specialised outpatient ser- more cost-effective, e.g. costly screening proce- vices. To this end, full use should be made of dures and programmes demonstrating a nega- available health care resources. The appropri- tive cost-benefit ratio as well as many services ateness of prescriptions should be enhanced by currently delivered during hospitalisation which implementing the relevant guidelines, encour- could be more appropriately provided in either aging the active support of prescribing doctors an outpatient clinic, a day-hospital, or in a resi- and promoting the dissemination of correct dential non-hospital facility. information to the general public. The 1998-2000 INHP makes provision for the The scope of the coverage provided evenly establishment of a national programme to across the board by the INHS - according to the develop, disseminate and evaluate guidelines, concept of “essential health care levels” - treatment and diagnostic patterns. requires identifying services which, because of The drawing-up of guidelines is a rather com- specific conditions or health hazards, have been plex organizational and methodological scientifically proven to be significantly beneficial process. It requires good technical knowledge to the health of the individual and/or the com- and proper resources aimed at: munity within the limits of the resources allo- • selecting clinical conditions and health care cated to them. services according to priority criteria; Consequently, the average budget (or quota) • winning the active involvement of all poten- does not include services which: i) do not meet tial recipients, i.e. health professionals, citizens the principle of effectiveness and appropriate- and administrators, when developing, dissemi- ness of interventions (which means that no nating and evaluating the guidelines; available scientific evidence supports their effec- • developing a process with phases involving tiveness and/or they are delivered to patients different INHS stakeholders and responsibili- whose clinical conditions do not meet the rec- ties: ommended indications); ii) fail to meet the prin- – the development phase, which must respond ciple of cost-effectiveness, (i.e. do not guaran- to specific methodological requirements relat- tee an optimal cost-effective ratio in terms of ing to gathering and evaluating scientific evi- resources as well as modes of service provision); dence and its consequent use in the formula- and iii) do not meet fundamental health needs. tion of guidelines; Change-promoting policies and strategies - 269

– the dissemination phase, to be carried out in – vaccination against influenza; such a way so as to ensure the widest possible – antibiotic prophylaxis in surgery access to all parties concerned; – pre-surgery diagnostics. – the implementation phase, which applies the Priority should be given to the development of guidelines to health care; guidelines identifying clinical indications relat- – the assessment phase, to evaluate the impact ing to outpatient or day care hospital services on health care quality and costs, also in order to with specific reference to elective surgeries for conduct timely updates and reviews of the carpal tunnel syndrome, vein ligation and guidelines themselves. removal in the lower limbs, cataracts, inguinal Conditions, procedures and action programmes hernias and cholecystectomies. should be selected according to the following Priority should be given to guidelines which priority-setting criteria: contain INHS overall expenditure. • incidence rates in the general population or in When expenditure exceeds its ceiling based on specific population subgroups; the availability of funds, Regions and • direct and indirect costs of diseases, and the Autonomous Provinces may define which health procedures and interventions related to their care services should be financed by the Region- treatment; al Health Fund (one exception refers to what the • variations in access to treatment, in services regulations in force make provision for in terms and/or in the final results; of regional self-financing). Services may be • feasibility based on available information; delivered by accredited public and private health • relevance with respect to national and region- care providers. All financing complies with the al programmes which pursue health objectives INHS governing principles and in consideration and promote the innovation of health care ser- of the various priorities in health services. vice delivery. Moreover, special attention is to be paid to the 1.3 Structuring health care preliminary assessment of the degree of effectiveness, cost-benefit and appropriateness of During the period 1994-1996 experience was the use of services and/or of innovative gained regarding the different strategies imple- approaches to health service delivery. mented by Regions and Autonomous Provinces Making advantage of national and internation- in Italy to meet the health needs of their resi- al experience, by the end of the INHP’s first year dents. The major changes brought about by the of operation, guidelines should be in place to enforcement of national and regional regula- regulate at least ten of the following clinical tions as well as the changed social and eco- conditions, interventions and action pro- nomic scenario recommend the restructuring of grammes which have been selected according health care a matter of priority. to the above-mentioned criteria: The redefinition of the guaranteed levels of – early diagnosis and treatment of hypercholes- assistance and the consequent reclassification terolemia; of activities and interventions therein, satisfies – backache; the need to introduce health services into the – pneumonia framework of the macro-areas set by present – bronchial asthma; regulations. – peptic ulcers; Health care is to be structured according to a – pregnancy; three-tier structure: – hypertension – health care in the living and working environ- – angina pectoris; ments; – breast cancer; – district health care; – cervical cancer; – hospital care. 270 - Change-promoting policies and strategies

The above three-tiered structure is based on the Ad hoc guidelines should be issued to foster following considerations: the interaction between the existing informa- a) the need to enhance the activities carried out tion flows and the new service monitoring and by the “Prevention Department” according to assessment patterns. Decree Law No. 502/1992 (and subsequent amendments and updates) and in an effort to 1.4 Determining the average budget per- further promote prevention activities. It is capita important to note that primary and secondary prevention activities (e.g. health education, The “average budget (or quota) per capita counselling, individual and risk-group preven- (“quota capitaria di finanziamento”) represents tion carried out by GPs and by other health pro- the national mean value per-person needed to fessionals) are also available at the district and finance the essential health care levels (capita- hospital levels (taking into account their allo- tion system). cated resources). In addition, prevention is The budget is set at a level which takes into delivered by non–health sectors, in pursuance account demographic, epidemiological and of a common goal to promote health which all organizational data recorded throughout the parties share; nation in the period immediately preceding the b) the need to encompass the three highly implementation of the 1998-2000 INHP and interconnected service delivery areas, i.e. prima- encompassing the entire Italian population. ry health care, specialist health care, communi- The budget per capita is calculated according to ty semi-residential and residential health care, reference parameters. These parameters are set within the single district macro-level. It should to determine each type of service - the exact be recognized that health care activities includ- amount of material or financial resources nec- ed at the district level may also take place with- essary to ensure the organization and delivery in hospitals (e.g. outpatient specialist care). of essential health care levels. Establishing a District contributes to further Physical parameters and their mean unit refer- strengthening District identity within a Local ence costs are calculated on the basis of the Health Unit by coordinating and integrating all outcome of the study conducted by the Work- non-hospital health-care services; ing Party in charge of monitoring and assess- c) the need to do away with a specific service ing health care levels set up by the 1994-1996 category, i.e. the activity organization support INHP (established within the framework of the level, previously identified as an individual cate- Permanent State/Regions Conference). Fur- gory, which interacts with the organization and thermore, the data issued by local health delivery of the activities provided by the other agencies and hospital agencies in compliance health services. with the relevant national regulations and in Each health care level is then broken down into consideration of the priority objectives defined sub-categories (Fig. X.3) which are identified on by the 1998-2000 INHP are taken into the basis of their expenditure items, supply pat- account. terns and the specific user groups that they To periodically verify the correct use of the address. Here, greater attention is given to the National Health Fund when monitoring health information requirements and specificity of care levels, the above-mentioned Permanent each sector. State/Regions Conference further develops the To monitor and evaluate the health care ser- set of parameters applied in previous fiscal vices provided to the population, the results years. They are merely useful for calculating the achieved and the expenditure ceilings set, average budget per-capita; as such, they do not actions should be taken to upgrade the infor- represent any reference value (or value-goal), mation system. cannot impose constraints on regional govern- Change-promoting policies and strategies - 271

ments as to their resource allocation, and do this respect, implementation proposals will be not set priority fund-allocation patterns. The implemented at the local level with the aim to budget per-capita is not to be read as the finan- solve the problems regarding the safety of cial equivalent of services to be provided to buildings. each and every resident. Furthermore, the 1998 Budget (Law No. The budget per-capita also includes the funds 450/1997) allocated (in table B) a total of ITL necessary to operate the INHS. When allocating 828 billion (249.5; 427.6 and 150.9 for each of resources, special attention should be paid to the reference years respectively) for the 1998- ensuring organizational, administrative and 2000 period to be used to satisfy specific regu- managerial services which are essential for the lations regarding the sector of new structures INHS to efficiently and effectively provide fun- and new projects supporting innovations in the damental health care levels. field of care for the terminally ill patients, for A technical document will describe in detail the improvements in the quality and operational methodology used to produce the budget per level of community service networks and non- capita in order to guarantee transparency at all hospital-based health care (e.g. home care). levels.

1.5 Financing Health Care Levels 2. TOOLS TO GUARANTEE HEALTH CARE LEVELS The INHS guarantees health services as defined in the 1998-2000 INHP by linking the budget 2.1 Meeting protection objectives per capita to inflation (which corresponds to a 3% increase compared to resources available in Pursuing health protection objectives by ensur- 1998). ing access to essential health care levels and in In consideration of the inflation rates and the compliance with the constraints imposed by real GDP growth rate, as provided for in the the health budget per capita, requires prelimi- 1998-2000 Economic and Financial Planning nary consideration of some unresolved issues Document, the budget per capita for health is pertaining to the Italian health system. Both set as follows: the ideal health service, which is the goal, and the steps to be taken in the transition process 1998 ITL 1 795 305 from the old to the new system, must provide 1999 ITL 1 849 165 for the unexpected and be able to respond (with a 3% increase over the 1998 rate) accordingly. 2000 ITL 1 904 640 To concretely develop the necessary tools, one (with a 3% increase over the 1999 rate) priority stipulated by the 1998-2000 INHP is the need to better define, also from a normative Capital expenditure for the 1999-2000 period perspective, some of the dimensions of the is financed by forecasts included in the 1998 INHS restructuring process set in motion by Act Budget (Act No. 449/1997) and amount to ITL No. 421/1992 which have not yet been proper- 240 billion, and to ITL 250 billion for the years ly outlined. Such aspects are fundamental to 1999 and 2000, respectively. the finalization of the process of change Regarding investments addressed to Local brought about by Law No. 419/1998 and the Health Agencies, a total of ITL 2 500 billion was Legislative Decree No. 229/1999. allocated for 1998 and 1999 (ITL 670 billion Therefore, the following are considered key and ITL 1 830 billion ITL respectively) when steps in the INHS restructuring process, and spe- entering the second phase of the ten-year plan, cific in-depth documents and operational guide- as provided by Art. 20 of Act No. 67/1988. In lines are to be developed for each of them. 272 - Change-promoting policies and strategies

a) National planning and INHS financing rently in force provide for new regulating tasks – redefinition of the local governments’ role in with respect to service providers. These tasks regional planning and socio-health integration; are to be performed in the authorization, reorganization of the health service cost-shar- accrediting and quality-control phases. Further- ing system and the revision of exemption, to more, Regions are expected to play a significant ensure greater equity in the distribution of role – still to be adequately developed – in pro- health cost burdens and avoid inappropriate viding guidelines to Local Health Agencies for use of the different health service provision sys- the development of their annual activity objec- tems (conforming with Art. 59, sub-section 50, tives and the setting of expenditure ceilings; Act No. 449/1997); – the definition of the double role played by – revision of the existing normative framework Local Health Agencies as being responsible both regarding the refund of INHS expenditure aris- for protecting people’s health and providing ing from health care relating to road accidents, them a with a health service. Regarding health occupational injuries and occupational disease protection, Local Health Agencies should provide victims (in conformity with Art. 38 of Act No. for health services within their own jurisdiction 449/1997); by utilizing service providers duly accredited by – definition of the financial system for Regions, regional governments. They should maintain the with reference to the allocation procedures of balance between funding provided by the resources available at the national level and in Regions through per capita budgets and service relation to the introduction of the regional tax provision expenditure. Regarding service provi- on the productive sector; sion, Local Health Agencies are responsible for – normative framework for complementary the management of their own jurisdictional health care provision in relation to primary structures and services, thus ensuring the bal- health care services; ance between the return on services provided – redefinition of the role of the Agency for free of charge and those that are not, as well as Health Services as a third party whose function its return on management expenditure; is to facilitate cooperation and coordinated – the definition of the funding formula for actions among the different levels of govern- regional governments and Local Health Agen- ment, also in relation to the innovations intro- cies with specific reference to the allocation of duced by Legislative Decree No. 281 of 1997 resources at both national and regional levels; and No. 115 of 1998. – the establishment of agencies with legal autonomy which can provide, through new b) Production and protection tasks integrated collaborative arrangements among – definition of a health planning system at both Universities and Regions, health services to the regional level, as provided for by the Leg- back up training and research, in compliance islative Decree No. 502/1992 bill and its succes- with national and regional health programmes; sive amendments, and at the local level in – the application of the accrediting system by accordance with guidelines still to be laid down the entire INHS; for: – the completion of the remuneration formula i) the protection of people’s health; revision process set in place by Legislative ii) the provision of services; Decree No. 502/1992, concerning the remuner- – the definition of the role of the Regions, ation of public and private health service which are responsible both for pursuing health providers; objectives and the balance between overall – the transformation of Local Health Units into financing and aggregate expenditure. As for Agencies implies the finalization of the corpo- the planning role played by Regions and ratization process for Local Health Units, the Autonomous Provinces, the regulations cur- establishment by regional governments of spe- Change-promoting policies and strategies - 273

cific regulations on economic, financial and of the 1998-2000 term, as provided for by Art. property management, the implementation of 12, sub-section 1 of Legislative Decree No. a cost-centre-based management accounting 502/1992. This allotment could be redefined system, and the adoption of an annual and and even readjusted to the project-undertaking pluriannual economic budget. capacity of regional governments, according to the provisions of Art. 1, sub-section 1 of Leg- 2.2 The financing of regional governments islative Decree No. 502/1992. The distribution and Local Health Unit Agencies parameters and timing of the allocations will be outlined in a specific technical document to be The following priority-objectives and measures drawn up within two months from the Plan’s are targeted at supporting regional and local approval. bodies in their pursuit of the objectives outlined • Regional governments are in charge of allo- in the framework for the financing system of cating the Regional Health Fund among Local Regional governments and Local Health Agen- Health Agencies (net amounts set aside to sup- cies, as provided for by the 1998-2000 INHP: port special programmes and regional projects), • Resources available at the national level are according to the allocation criteria followed at allocated among Regions and Self-governed the National level. Provinces according to per capita budgets. • In order to target resource allocation at ensur- These allocations are linked to the specific ing essential health care levels, Regional gov- demographic and socio-health features of the ernments are responsible for issuing necessary population of each Region as provided for by guidelines to identify the health care priorities the general criteria and provisions laid down in to be financed, as well as the functions and Art. 1, sub-section 34, of Act No. 662 of 23 activities to be boosted or limited. In particular, December 1996. the former should especially deal with preven- • According to Art. 1, sub-section 34, of Act tion, intended as health care to be provided No. 662 of 23 December 1996, and to its sub- both in living and working environments and in sequent amendments and revisions, regional districts (with special reference to the activity of governments are responsible for devising spe- General Practitioners), while the latter should cific actions to be funded by National Health address issues such as hospitalization. Fund committed allocations. The allocations are • To avoid any possible difficulties for Local for financial programmes which comply with Health Agencies which at the territorial level, the following criteria and parameters: are provided with operationally complex health – they must be inter-regional; service delivery structures (subject to full-charge – they must be pluriannual; remuneration), regional governments can – it must be possible to assess and monitor their establish criteria to be followed for allocating medium- and long-term objectives. regional funds which are specifically aimed at Furthermore, these programmes must comply counterbalancing the impact on expenditure of with or be consistent with the following priori- the classification of charges borne by Local ties: Health Agencies. – reducing social and territorial inequalities in • To ensure that the provision of the funda- health; mental health care levels contained in National – adopting truly effective prevention pro- and Regional plans, each year the Regional gov- grammes; ernments and Local Health Agencies are – resolving problems related to structural defi- requested to establish goals and indicators to ciencies in the health system. be used for assessing and meeting these goals. To this end, an allotment amounting to 3% of Furthermore, each year they are requested to the National Health Fund is used for each year determine the allocations for variable and addi- 274 - Change-promoting policies and strategies

tional allotments for remunerating general 2.4 Accrediting of health sectors managers and strategic directorates. The accreditation system has been devised as a 2.3 Remuneration for health service pro- means for submitting service providers to a viders screening process aimed at ensuring quality health care services. It is normally implemented To integrate and complete the remuneration in accordance with planning needs for the ben- systems for public and private service-providing efit of health services, taking into account the facilities, the 1998-2000 INHP specifies the fol- needs of the community, the health care service lowing: requirements and the financial resources avail- • set criteria to be followed in the definition of able. the ‘payment for service’ system for its applica- Accrediting public and private service providers tion and identification of the activities to be is needed to identify those facilities which, in remunerated through specific funding pro- compliance with certain specific agreements, grammes, which could be either alternative or are to provide the services included in the Local complementary to the charge system; Health Agencies’ annual and pluriannual activi- • identify the financing procedures tailored to ty plans. standard production costs as well as objectives The following are the accrediting system’s basic to be achieved for those activities to which the features, as provided for by Legislative Decree ‘fee for service’ system cannot be applied; No. 502/92 and its amendments, as well as by develop productivity assessment systems for the the Presidential Decree of 14 January 1997: remunerated structures; • public and private health service providers are • revise and update charge remuneration equally entitled to accreditation; systems for public and private service • the requirements for implementing the providers and simultaneously establish crite- accrediting system are different from the mini- ria for the classification of service-providing mum authorization requirements provided for structures. by the Presidential Decree dated 14 January • define and implement adequate and sys- 1997; tematic monitoring tools which may enable • Regions and self-governed Provinces are enti- Regional Governments and Local Health tled to establish accrediting criteria and to give Agencies to control the performance of pub- accreditation status to health facilities. lic and private service providers, with special The accrediting system guarantees a certain reference to the variations in the mix of the dynamic feature to quality requirements since services provided, the selection and adequacy the latter must be constantly reviewed in rela- of such services, and the quality of health care tion to the upgrading of health technologies provided; and practices. Furthermore, they always need • develop guidelines for issuing preliminary to refer to the health care process and out- Activity plans by Local Health Agencies, as pro- comes as to provide patients with both effec- vided for by sub-section 8 of Art. 2, Act No. tiveness and safety. In addition, there is a need 549/1995. Such plans should define the volume to include personnel training activities aimed at and type of services to be contracted to public fostering health care quality, maintaining quali- and private sectors, as well as to accredited ty levels and ensuring proper use of services health professionals, in compliance with pre- and treatments. specified expenditure ceilings, health care qual- Accrediting criteria need to be fully transparent ity requirements, and monitoring the degree of and widely disseminated in order to enable consistency between services delivered and pre- users and their representative organizations to scriptions issued. easily evaluate the services provided on the Change-promoting policies and strategies - 275

basis of subjective and objective factors related Within the 1998-2000 term, the Plan proposes to personal fulfilment and satisfaction. As such, the following objectives: accrediting can be considered as acknowledg- • devise mechanisms targeted at ensuring and ing the rights of safety and security to which supporting the implementation of health care individuals are entitled. quality assessment and promoting activities by To apply the accreditation system, the following health professionals and private and public objectives must be met within the three-year accreditation facilities; term: • organize systematic methods for health care • implementing accrediting criteria and proce- and medical practice revision and self-evalua- dures in all Regions and self-governed tion for each service, as well as for the diag- Provinces; nostic and therapeutic services provided for by • organizing specific training activities for a suf- Act No. 662/1996; ficient number of assessors of the quality • revise and extend the indicators’ system, requirements identified as essential by accredit- already provided for by sub-section 3 of Articles ing-applying health facilities; 10 and 14 of Legislative Decree No. 502/1992 • supporting regional governments in develop- and established by the Ministerial Decrees of 24 ing technical accreditation tools so as to ensure July 1995 and 15 October 1996, in order to homogeneity at the national level; assess the impact of the ‘remuneration for ser- • monitoring, with the support of the Regional vice’ mechanism on hospital and outpatient care; Health Service Agency, the implementation of • encourage recognition of the fact that active the accrediting system, with specific reference participation, in both the assessment and pro- to the relationship between facility require- motion of Local Health Agency, quality health ments and the accreditation process, and care is part of the institutional tasks of the INHS between accreditee and accreditor. personnel; The Plan aims to provide guidelines for the • allocate part of the INHS targeted research homogeneous implementation of accreditation funds to the National Quality Plan; at the national level. • foster the feedback from users and user organizations concerning the health services provided. 3. A NATIONAL QUALITY ASSURANCE PLAN

Changes currently taking place in the Italian 4. SAFETY OF HEALTH FACILITIES National Health Service provide for new opportunities and, at the same time, also entail new With reference to the general objective of pro- responsibilities in terms of quality of health tecting health at work, the 1998-2000 INHP care, at all levels within the system. specifically aims to enhance safety in both pub- The 1998-2000 INHP is primarily targeted at lic and private health care facilities. ensuring basic quality in health care by means Public and private health facilities implement of a National Quality Plan. This plan would sys- the provisions contained in Legislative Decree temize health care quality assessment and pro- No. 626 of 19 September 1994, and No. 242 of mote, involving the professional, corporate and 19 March 1996. relational dimensions of such assessments. The All production units are provided with an inter- objectives related to each of these quality nal prevention and protection system and with dimensions, the activities performed and the fire-fighting and evacuation measures in case of results achieved must be clearly indicated in the danger; moreover, a risk assessment document “Charter of Services” which should be adopted is provided for reference as well as training by all Local Health Agencies. courses for personnel. 276 - Change-promoting policies and strategies

All provider facilities are required to comply aging Directors of Local Health Agencies and with structure and equipment safety regula- the representatives of associated Municipalities tions, in particular when the equipment is for in compliance with regional regulations deriv- electromedical use; the funds provided for ing from the implementation of Art. 3 of Leg- under Art. 20 of Act No. 67/1988 are allocated islative Decree No. 112 of 31 March 1998. High to this priority goal; competent bodies are in priority must be given to integration in regional charge of ensuring immediate equipment type- plans to which earmarked resources must be approval when necessary. Prevention depart- assigned, with special reference to highly inte- ments are in charge of ensuring that periodical grated areas requiring specific targeted pro- equipment checks are carried out. jects. In this context, priority should be given to Local Health Unit Agencies in charge of preven- activities related to maternal and child care; the tion and safety at the workplace must upgrade handicapped; the elderly, especially if not self- their operational structures in order to ade- sufficient; mental health; drug-addiction; con- quately monitor the enforcement of the regula- ditions which require prolonged and continu- tions. ous care, especially with reference to cancer and HIV infections. In particular, socio-health integration must be 5. INTEGRATION BETWEEN HEALTH CARE implemented and assessed at three different lev- AND SOCIAL ASSISTANCE els: institutional, managerial and professional. • Institutional integration stems from the need The integration of different health policies: to promote collaboration among different insti- • stems from close relationships between pre- tutions (e.g. local health units and local govern- vention, treatment and rehabilitation; ments) aiming to achieve common health • rests on health care continuity between hos- goals. It can refer to a broad range of legal pitals and other health care facilities; instruments, such as conventions and pro- • enhances the accountability of different cen- gramme agreements (agreed upon by about tres; half of the Local Health Agencies, mainly • qualifies the relationship between public and regarding the area of geriatric care). private bodies; The District is the operational structure which is • promotes solidarity and health investment in best equipped to manage integration among local communities. institutions as well as among the different resources provided by the INHP, the municipali- 5.1 Socio-health integration ties and local solidarity. Health care integrated processes will undergo strict monitoring by The integration of responsibilities and resources these Districts, which will also be in charge of is fundamental to enhancing the effectiveness linking the measurable outcomes to the avail- of health interventions. It has a major impact able resources to the results achieved. on health care continuity and closely affects the To this end, Regional governments will include, relationship between hospitals and the commu- financing criteria and organizational trends in nity, hospitalization and home-care, as well as their socio-health plans thus providing Local general and specialist medicine. Health Agencies with the opportunity to plan For this reason and also in relation to the new for the resources to be allocated to each District. and different tasks attributed to Municipalities • Managerial integration affects the operational by the modifications of Legislative Decree No. unit level ensuring uniformity within the District 502/92 (see Chapter XV) district-related action and specifically within health care providing planning is to be encouraged and promoted. facilities operating in the District. It allows for This must include the collaboration of the Man- the identification of organizational patterns Change-promoting policies and strategies - 277

and coordination mechanisms which may sup- health care flexibility and effectiveness. Home port the effective development of activities, care becomes integrated (IHC) when different processes and services. health and social professionals cooperate in At the management level, project-oriented order to implement projects tailored to a methodologies and multidimensional approa- patient’s various needs. ches should be enhanced. Planning IHC implies integration among the dif- Multiprofessional units must take into account ferent health care modules, as well as the the allocation of resources provided by health enhancement of nursing skills and the collabo- and social budgets from Regional governments ration of patients’ families, bearing in mind that using the instruments of management account- close cooperation between hospitals and dis- ing and the corresponding accountability cen- tricts can also enable non-self-sufficient people tres. to be treated in their homes. Assessment measures are closely related to the Integrated home care must rely on the system- latter and must be included in the districts’ atic planning of each district’s health service information system. To this end, provision must providers entailing a multidimensional assess- be made for adequate users’ evaluation proce- ment; the holistic aspect of the treatment plan dures. and its intensiveness; the therapeutic continuity • Professional integration is closely linked to the of the services; collaboration between health adoption of business profiles and guidelines and social professionals; the cost-assessment of aimed at orientating interprofessional work in the actions to be undertaken; the collaboration the field of health service delivery (home care, of the patients’ families and the evaluation of intermediate services and residential care). the outcomes. Professional integration must rely on the estab- District information systems and the systematic lishment of integrated assessing units; unitary analysis of the costs related to the intensity and documentation management; the economic complexity of the health services rendered by impact assessment of measures to be taken; each different provider will provide the basis for the definition of responsibilities within the inte- the evaluation centres to assess outcomes. grated work system; therapeutic continuity between hospitals and districts; collaboration 5.3 District between residential and territorial facilities; the establishment of appropriate health care mea- The District represents a health service-provid- sures to be tailored to the types of actions ing centre, where health care demand is man- implemented; and the use of integrated service aged in a global and uniform way. complexity indices. It is an operational structure of the Local Health Agency. Its autonomy is ensured in accordance 5.2 Integrated homecare with the programmes approved by the same agencies, taking into account the area-related Home care implies a radical change in tradi- service plans as established with local govern- tional health care approaches: the focus shifts ments. on patients relying on health care providing The size of the District is set according to the facilities as well as hospitals, to services that are guidelines provided for by Art. 2 of Legislative tailored to meet the needs of patients in their Decree No. 502/92 and its successive amend- home environment. ments. The characteristics of both the area, There are several ways in which districts can population distribution and its productive activ- provide patients with home care services. Home ities are also taken into account. care, and in particular integrated home care, The organizational structures will depend on the represents a unique opportunity to ensure number of health care services provided and the 278 - Change-promoting policies and strategies

nature of these services. When resources and public administration imply a radical shift in production are equal, the Districts’ organiza- mentality, a new professional culture and oper- tional profiles may differ from one District to ational logic. In particular, this change requires: another, depending on local strategies. • individual and collective accountability in the Districts are responsible for ensuring that peo- context of integrated services, in terms of both ple have access to basic health services with the quantity and appropriateness of the ser- clear methods and defined timing through a vices provided; network of on-line systems that link all health • overcoming of sectorial positions based on service providers. Finding health services, both the specific interests of single professionals or out-patient and hospital based, shall be guar- groups of professionals; anteed by Districts to all area residents. • flexibility in the use of human resources which Within the Districts, General Practitioners and need not be constrained by pre-set space and pediatricians chosen by a resident are the direct time patterns and always in compliance with reference points for people and families. They the roles provided for and recognized by the are in charge of promoting and fostering health contract; and for evaluating the real needs of the people • revision of contractual and regulatory provi- so as to orient and ensure access to the Nation- sions in order to make personnel recruiting eas- al Health Service. ier and more effective; Districts benefit from resources allocated by • use of remuneration systems that allow for Local Health Agencies which are proportional differences in the quality and quantity of ser- to the volume of activity planned in each Dis- vices delivered by each individual provider, and trict. In order to optimize District services, also within the same professional category; regional governments must specify in their • gradual overcoming of public employment plans the home care, intermediate and residen- constraints consistent with the needs imposed tial care services to be delivered and the differ- by corporatization; a distinction should be ent financing sources. made between the public nature of services Professional, economic and other types of delivered and the private nature of labour reg- resources in a District are managed by the exec- ulations; utive responsible for that District. General Prac- • revision of the incompatibilities among exist- titioners, together with other health and social ing regulations so as to relieve exclusive con- sector operators, play a very relevant role and tractual relationships in the short-term. are integrated into the District’s organization. For the full development of this framework, executive directors are called to play a critical role. They must, therefore, be appointed to: 6. HUMAN RESOURCE MANAGEMENT • privilege competencies targeted at optimizing resource management and integrating produc- The user/health professional relationship is tive factors; strongly characterised by the level of human • distinguish between two types of executive and personal input as well as the appropriate functions, namely those aimed at the manage- nature of the service provided. For this reason, ment of resources and those which mostly refer the human factor is a strategic element in the to the professional responsibilities involved; provision of services, since it has a significant • promote the accountability of decision-mak- impact on health care service quantity and ers in charge of expenditure management. quality, as well as on the users’ fulfilment and In order to further these objectives, it is neces- perceived satisfaction with the service provided. sary to complement national regulations with The processes of change in the health system as strategies outlined at other jurisdictions on key well as in the contractual relations within the issues, such as the definition of collective con- Change-promoting policies and strategies - 279

tracts, planning and monitoring activities, care should be devoted to the basic conditions regional directives, and integrated labour effec- which are necessary to boost training effective- tiveness guidelines. ness. Training must not merely depend on the soundness of the contents and methods adopt- 6.1 Training ed, but it must necessarily rely on its capacity to approach problems at their very root and con- Training is an effective tool for optimizing sequently fully involve the professionals who human resources and organizational changes. are called upon to tackle such problems. Training initiatives play a fundamental role in For this purpose, it is necessary to develop the upgrading of professional skills and exper- training programmes on the basis of prelimi- tise and foster continuous cultural improve- nary assessments carried out on expected train- ment. Moreover, they provide effective support ing impact and effectiveness in compliance to service development programmes and must with the guidelines established at the national therefore be implemented within the frame- level. Moreover, training should also be devised work of consistent integration with organiza- so as to permit results to be assessed in the tional policies for employing personnel and medium- and long-term. with a view towards careful forecasts of profes- Management training should be further sional needs. enhanced and targeted at those professionals By its very nature, training can effectively who are directly employed in resource and ser- improve the quality of health services by vice management, and should therefore focus accommodating organizational shortcomings. particularly on management techniques and Moreover, it can facilitate professional requalifi- quality promotion. cation and serve as a strategy for boosting ser- When training addresses especially complex vice effectiveness. problems, it should involve all the parties con- Training must be planned in accordance with cerned, including interprofessional groups, the quantitative and qualitative features of intercorporate groups and/or professionals medical and non-medical personnel as well as from different institutions. with national and regional goals. In particular, Regional governments should encourage train- training should be organized in parallel with ing and investment programmes. This is espe- Local Health Agency programmes and always in cially so when training addresses problems of relation to the three levels of health care indi- common interest and engages interprofessional cated in the INHP. The National government will working groups and service providers. Special periodically supply the competent authorities reference should be given to project work, doc- with helpful guidelines for the streamlining and umentation and assessment of the measures to cost-effectiveness of personnel training initia- be implemented and their orientation toward tives. To make planning possible by the Italian greater “humanization”. Ministry for Universities and Scientific and Tech- The role of public and private training providers nological Research as regard access to health- operating within the INHS is particularly rele- oriented professional schools and faculties of vant for the implementation of training activi- medicine, the allocation of the number of ties. The National and regional governments places available for specialist training in health are in charge of promulgating accrediting pro- care management among the different schools cedures and regulations for such providers, as must be limited. This is to be done in conjunc- well as for the criteria that must serve as a basis tion with the Ministry of Health, having already for the training programmes organized within acquired the opinion of the Permanent the INHS. State/Regions Conference which will determine Issuing national guidelines may allow different health care personnel requirements. Special objectives to be achieved by providing evalua- 280 - Change-promoting policies and strategies

tion standards and methodological procedures National Health Research and Development to connect the training outcomes with the Programme; such a programme will be target- effective implementation of fundamental ed at meeting the needs of the INHS in terms of health care levels. knowledge and organization, and will be financed by allotments earmarked by the National Health Fund. 7. RESEARCH, EXPERIMENTATION AND The funds available will be allocated according DEVELOPMENT to the different types of research. A distinction will be made between current expenditures for The adoption of an effective research strategy research and targeted research (which address- based on the need for scientific evidence and es specific health care and biomedical issues). knowledge necessary for health-policy develop- Targeted research will involve all the institution- ment, health care measures planning and al bodies of the INHS and the regional govern- health care and medical practice organization, ments (the latter particularly to carry out health represent basic requirements in the pursuit of care researches). These institutional reference health care objectives and in assessing the partners should act as coordinators of research effectiveness of interventions. activities to be carried out jointly and eventual- As such, scientific research plays a significant ly co-financed by Universities, the National role in the planning of health-improving poli- Research Council and all other research bodies. cies; all the policies implemented in this field The harmonization of health care research are soundly supported by biomedical and strategies and tools with INHP objectives will be health care research. agreed upon jointly by all the ministries con- Such a strategy is based upon: cerned. On the basis of the 1998-2000 INHP • finalisation the objectives provided for by the objectives, it is possible to identify those areas of 1998-2000 INHP; activity to be enhanced and further developed • coordination with general research policies at by the National Health Research and Develop- the National level (in accordance with the recent ment Programme (Table XIV.1). These include: reorganization proposals put forward by the • an assessment of the practical effectiveness of Italian Ministry for Universities and Scientific main health procedures and measures; Research) and at the international level (as pro- • experimentation with the health service’s vided for by the European Union’s Fifth Frame- operational and organizational systems provid- work Programme and the World Health Organi- ing people with effective health care; zation research plan). As for applied health care • assessment of the most effective procedures research, it is necessary to coordinate, in relation for directly translating biomedical research to the objectives of the INHP, all the activities results into health care and medical practice; carried out by the different National research • experimentation with the effectiveness of dif- bodies (e.g. the National Research Council, the ferent managerial models and assessment of Italian Ministry for Universities and Scientific and their impact on the health indicators of the Technological Research, and the National Insti- population; tute of Nutrition); • experimentation of measures aimed at • streamlining of the activities undertaken, improving people’s knowledge about the effec- through the coordination of research carried tiveness of medical treatments and improving out by NHS scientific and technical bodies and the capacity of health professionals to commu- the development of collaborative interdiscipli- nicate with patients and involve them in deci- nary projects. sions which concern their health; On the basis of these objectives, the National • assessment of the effectiveness of measures Health Care Research Committee will devise a and technologies which, although relevant to Change-promoting policies and strategies - 281

the INHS, have not undergone previous clinical measures adopted as well as cost-efficiency experimentation to assess their effectiveness assessments. This collaboration should focus on yet. areas requiring a “systematic revision” of the In order to rapidly implement the above-men- information available (this could be furthered tioned directives which should be directly sup- by developing synergies and collaboration with ported by the INHS at the National, regional other European countries) and on the imple- and local levels, it is of the utmost importance mentation of multicentred clinical trials in that a close link between research and produc- accordance with the accepted standards for tion be established. This should foster develop- testing models in the field of assessing the ment-oriented strategies aimed at priority areas effectiveness of diagnostic and therapeutic and biomedical research enhancement. In par- measures, as well as for health care services. ticular, special attention should be devoted to Another area of collaboration between the the development of research activities that INHS National Health Research and Develop- could have a major impact on INHS organiza- ment Programme and industry should be a tion, functioning and clinical practice. focus on outlining integrated health care strate- Fruitful collaboration should be cultivated in the gies aimed at testing field-based models that fields of effective evaluation and cost-effective could ensure both quality- and cost-effective- technologies, and in the effectiveness of the ness.

Table XIV.1: Research, Experimentation and Development: Priority Areas

Pursuing the health and resource allocation goals anticipated by the 1998-2000 Italian National Health Plan implies drawing up a complex and articulated National Health Research and Develop- ment Programme which can systematically identify priority areas, with special reference to the following development areas: • disease prevention and health promotion; • assessment of the health care system’s impact on health and risk factors; • assessment of the veterinary public health impact on human health; • analysis of the social and ethical aspects of health care; • analysis and assessment of users’ information needs and effective communication models; • economic analysis and the assessment of health measures; • study and experimentation of clinical and organizational guidelines and assessment of their impacts; • economic analysis of the health services provider sectors operating within the health care system; • assessment of the economic and organizational impact of health care technologies; • development and experimentation with new management and organizational models; • experimentation and assessment of the impact of different compensation systems on the health measures implemented and on the health of the population; • assessment of the impact on health of the integrated socio-health measures. CHAPTER XV

ITALIAN HEALTH SERVICE REFORM

CONTENTS

1. THE “LEGGE DELEGA1” NO. 419/1998 FOR THE REFORM OF THE ITALIAN NATIONAL HEALTH SERVICE ...... 284

2. THE LEGISLATIVE DECREE NO. 229/1999 IMPLEMENTING THE “LEGGE DELEGA” FOR THE ITALIAN HEALTH SERVICE REFORM . . 285

1 Please note: throughout this Chapter, the term “Legge Delega” refers to an act conferring delegated legislative power to the government. This power is exercised through the approval by the Council of Ministers of a draft legislative decree which is submitted to the non-binding scrutiny of competent porliamentary committees and, finally, adopted by the Council of Ministers (see also Annex 9). 284 - Italian health service reform

1. THE “LEGGE DELEGA” NO. 419/1998 FOR clause a). Secondly, such points of the Law can THE REFORM OF THE ITALIAN NATIONAL also be found in the wish to streamline the HEALTH SERVICE most innovative part of the legislation of 1992/1993, which is centered on the regional- The Italian National Health Service (INHS) was ization of its structures along business lines, as established by Law No. 833 of 23 December well as in delegated regulations which should 1978 and it was largely revised by Legislative “complete the regionalization process and ver- Decrees No. 502 in 1992 and No. 517 in ify the process of reorganizing the structures 1993. of the INHS along business lines. Law No. Law No. 419 of 30 November 1998 (Annex 9) 419/1998 also aims to strengthen the role confers delegated legislative power to the Gov- played by municipalities which is now being ernment regarding the streamlining of the reconsidered in the procedures of health and National Health Service and the adoption of a socio-health-related planning at both the consolidation act for the organization and func- regional and the local level, even though tioning of the National Health Service. The municipalities (clause c) remain excluded from amendments to Legislative Decree No. 502 of 30 direct management functions and responsibil- December 1992 consist of four distinct legisla- ities within the INHS. tive delegations. The first, contained in Article 1 The “Legge Delega” supplements these basic of law 419/1999, concerns the modification and choices with some important specifications integration of the reorganization initiated by regarding the role of some institutes provided Decrees No. 502 and No. 503 of 1992 and 1993 for by the present legislation, but which - also on the basis of a substantial series of guiding on account of the subsequent amendments to principles and criteria (to be exercised within 180 this legislation (not only the amendment Act of days from approval). The second, contained in 1993, but also a whole series of urgent mea- Article 4, concerns the issue of a consolidation sures, together with the periodic adjustments act of the laws and other acts having the force on the occasion of the regulations associated of law concerning the organization and func- with the annual budget), have never had the tioning of the National Health Service (to be benefit of a coherent and clear normative defi- exercised within eighteen months); the third, nition. contained in Article 5, concerns the re-ordering This is the case of the principle of free choice, of prison medicine (to be exercised within six which Law No. 419/1998 must guarantee, months); the fourth, contained in Article 6, con- ensuring “that its exercise by the beneficiary cerns the redefinition of the relations between vis-à-vis the structures and the accredited pro- the National Health Service and the universities fessional men and women with whom the INHS (to be exercised within one year). maintains appropriate relationships should take The central points of Law No. 419/1998 lie place within the framework of health plan- above all in the confirmation of the impor- ning” (clause d)). tance of the INHS as the instrument through Similarly, as far as the accreditation institute is which the institutions perform the constitu- concerned, the normative importance of which tional task of safeguarding health. In this con- has given rise to an extensive debate also at the nection, it is highly significant that the first jurisprudential level, the “Legge Delega” principle and criterion of delegation should be speaks of the need for the decree to define “a that of “pursuing the full realization of the model of accreditation in line with the orienta- right to health and the principles and objec- tions of the Italian National Health Plan (INHP), tives laid down by Articles 1 and 2 of Law No. in application of the criteria laid down by Arti- 833 of 23 December 1978 and subsequent cle 2 of the Presidential Decree of 14 January amendments thereof” (Article 2, para.1, 1997”. According to this latter Decree, the Italian health service reform - 285

Regions should keep with their own planning 2. LEGISLATIVE DECREE NO. 229/1999 choices, and thus automatically distinguishing IMPLEMENTING THE “LEGGE DELEGA” accreditation from the authorizations both to FOR THE ITALIAN HEALTH SERVICE implement health structures and to carry out REFORM health care activities (provided for by clause dd), and, as has been seen, from the appropri- Compared with the needs defined by the ate relations referred to in the aforementioned above-mentioned “Legge Delega”, the imple- clause d)). mentation given by the Legislative Decree No. In this context, the “Legge Delega” asks the 229 of 19 June 1999 (S.O.G.U. 16 July 1999) Government to specify the role of the various concerning the norms for the streamlining of operators whose job entails providing health the INHS follows the direction of the overall care, according to whether they are, public rationalization of the INHS. It identifies the operators or equivalents thereof, private non- levels of autonomy and the corresponding profit-making and private commercial opera- levels of responsibility of each institutional tors, “with a view to attaining the health objec- subject, as well as the various categories of tives defined by health planning” (clause c); see operators of the INHS, and defines a general also clause ll)). model of how the INHS functions, making the Likewise, the “Legge Delega” calls for a defin- Regions responsible for ensuring the manage- ition of the distinctive criteria and the charac- ment of the INHS through Local Health Unit terizing elements for the identification of Local Agencies, Hospital Agencies, Health Care Health Unit Agencies and Hospital Agencies, Institutes of a Scientific Character, as well as “with particular attention to their minimum the health assistance activities of the Agencies organizational characteristics and the national to be defined in the provision referred to in or interregional importance of the Hospital Article 6 of Law No. 419 1998. In the context Agencies (clause ii), and “establishing the of their respective competencies, it is a duty times and the general modalities for the acti- of the Regional Governments and Local vation of districts”, not least for the purpose Health Unit Agencies to ensure that health of “arriving at an efficient integration at the service as provided for by each essential level district level of the health services and their of assistance are actually delivered, by enter- social counterparts” (see clauses bb) and n ing into suitably drawn up contracts which are respectively). based on estimated cost-accounted activities As regards the Italian National Health Service with various public and private sector accred- and the overall streamlining of human ited health structures chosen on the basis of resources – also by means of the instruments their cost-effectiveness. and strategies of health research – the “Legge Article 1 of Legislative Decree No. 229/1999 Delega” not only confirms the choice of a replaces paras. 1 and 2 of Article 1 of Legisla- mutually exclusive employment relationship tive Decree No. 502 of 30 December 1992 in between the Health Service and its managers, implementing the principle referred to in Article through the extension of private employment 2, para. 1, clause a), of the “Legge Delega” of contracts to them (clauses q and o)), but also 30 November 1998 (Annex 9), reaffirming the redefines the requirements to be satisfied by constitutional principle of health protection as a the General Managers (clause u) requiring the fundamental right of the individual and the decree to establish norms for “ensuring the concern of the collectivity and redefining it rationality and cost-effectiveness of the inter- from an operational viewpoint. The implemen- ventions in the field of training and profes- tation of the right is entrusted to the INHS, sional development of health personnel” which has the task of ensuring – through pub- (clause v)). lic resources – equal access to health services. In 286 - Italian health service reform

keeping with the evolution of the State in a The procedure for drawing up the INHP has federal direction and in implementing the prin- remained unchanged. With a view to stimulat- ciple of conferring delegated legislative power ing the Regions to perform the task within their to complete the regionalization process, the competence, it has been established that the INHS is characterized as the rational system of absence of the Regional Health Plan will not linking and harmonizing the functions and render the provisions of the INHP inapplicable. activities of the Regional health services, in as Article 2 of Legislative Decree No. 229/1999 much as it is mainly the Regions’ responsibility amends Article 2 of Law Decree No. 502 of 30 to ensure a system made up of essential levels December 1992, specifying and extending the of health care, guaranteeing the promotion of government functions attributed to the Regions health as well as the prevention, treatment and in the light of the wider management autono- rehabilitation of illness and disabilities (see sec- my granted to the health agencies by Article 3 tion XIV). and the more incisive presence of the local More particularly, paragraph 3 of the article authorities in the planning and evaluation of under consideration, which specifically deals health services. with health planning and resources allocated This article redesigns the system of relationships to the safeguarding of health at the national between Regions, local authorities and health level, expressly attributes to the Regions the Agencies, entrusting appropriate Regional Gov- task of drawing up – either singly or through ernment acts with the task of regulating the the self-coordination instruments – proposals role of the local authorities in health planning regarding the elaboration of the INHP with ref- agencies. In implementing the principles set out erence to the needs at the territorial level and in Article 2, clause l) of Law No. 419/1998, this the interregional functions that are to be given role has been strengthened at the Regional priority. level, providing for the establishment of a Per- A similar participatory function is given to the manent Conference for Regional Health and Regions when determining the overall needs of Socio-Health Planning, which will have an advi- the INHS and evaluating of its compatibility sory role in drawing up the Regional Health with national social and economic planning. In Plan and verifying that the local implementa- this connection, the Regions are to transmit – tion plan has been carried out; at the agency not later than one hundred and twenty days level, again, it provides for a local implementa- prior to the approval of the annual Economic tion plan to be approved by the Conference of and Financial Planning Document – their annu- Mayors of the Municipalities within the territo- al Report on the State of Implementation of the ry covered by the Local Health Unit Agencies, Regional Health Plan concerning the manage- while at the district level the territorial health ment and expenditure results expected for the plan is to be elaborated and agreed upon also year to come. The precise purpose of this is to by the Conference of Mayors of the Municipal- ensure the essential health care levels estab- ities within the District. lished by the INHP. Furthermore, Article 2 strengthens the centrali- Therefore, the financial resources to be allocat- ty of the Region’s role in defining the territorial ed to health protection can be defined by tak- frames of the Local Health Unit Agencies, in ing into account the reports submitted by the their grouping into Districts and in defining the Regions, as well as of the essential levels of funding criteria, as well as in identifying the health care provided for by the INHP. The latter principles and the criteria on the basis of which comprise the assistance typologies, the services the General Managers are responsible for the and benefits relating to the specific sectors act of organization and functioning which identified by the INHP 1998/2000 and specified forms the basis of the setting up of health in paragraph 5. agencies provided for by Article 3. Italian health service reform - 287

The system of links between the Region and an original model for health Agencies that does health agencies on the one hand and between not totally coincide with any of the currently Regions, local authorities and health agencies known forms of Agencies. They are governed on the other, is completed by the definition of by private law, but conserve a public legal per- the relationships between State and Regions, sonality and are called upon to meet the health by means of identifying the procedures to be objectives set down by national and Regional followed in cases where the Region proves planning in full respect of the budget con- incapable of performing its individual duties. straints. Paragraph 2-octies of Article 2 constitutes a To this end, provision is made for the Local regulation of principle and general reference in Health Unit Agencies and the hospital units in the matter of powers of intervention in the rela- possession of the requisites set out in Article 4 tionship between the State and the Regions. to constitute themselves as agencies enjoying This provision is integrated by Article 19-ter, both a public legal personality and business which defines in greater detail the interventions autonomy, managing themselves under provi- to ensure the functionality and efficiency of the sions laid down in private law applied by the health service. general manager, in full compliance with The provisions of paragraph 2-septies, which Regional requirements. implement the principle set out in Article 2, Recognition of entrepreneurial autonomy mod- para.1, clause c), of the “Legge Delega” quali- ifies the previous judicial formula of the Agency fies private non-profit-making associations, by underlining the private nature of business which are appropriately redefined - by refer- activity, adopting the keenest instruments of ence to Law Decree No. 460 of 4 December private law also for the organization, function- 1997 regarding non-profit-making organiza- ing, acquisition and combination of the pro- tions of social usefulness - as structural ele- duction factors as well as the use of human ments of the public health service by virtue of resources. their consistency with the objectives and the The streamlining of the external activities is organization of government. They, therefore, entrusted to the integral application of private cooperate with the public structures perform- law, within the limits of national and Commu- ing their constitutional duties of solidarity. nity legislation in the matter of public tenders Article 3, of Legislative Decree No. 229/1999 for supplies and service, and on the basis of an which renews and integrates Article 3 of Leg- autonomous contract defined in the manageri- islative Decree No. 502/1992 regarding the al act of determining how it functions and is organization of the health Agencies, calls for a organized. model of an Agency which can effectively and Paragraph 1-quater vests full responsibility for simultaneously satisfy all the fundamental func- the Agency in the general manager and the tions required of businesses to operate within Board of Auditors and makes provision for the the health system; the guarantee of equal of former to avail of the services of Health Man- access to the services in keeping with the need ager and Administrative Manager, but also of for assistance; efficacy of the prevention inter- the socio-health manager, apart from when ventions, treatment and rehabilitation interven- otherwise determined by the Region. tions; efficiency in the production and distribu- Paragraph 1-quinquies defines the responsibility tion of the benefits and the services which are of the strategic direction of the Agency, both necessary and appropriate according to strengthening its collective character, making the conditions of each user. The need to quali- provision for the involvement of the health man- fy the Agencies as businesses, which are pro- ager, the administrative manager and the socio- vided with their own resources and entrepre- sanitary manager, who nevertheless conserve neurial autonomy, has led legislation to create their specific direct managerial responsibilities. 288 - Italian health service reform

The additional Article 3-bis regulates, in partic- the activities of the services and of the depart- ular, qualifications that the people holding ment’s Local Health Unit Agency, inclusive of these posts must possess, procedures for their the hospital units, both with each other and appointment, as well as periodic re-assessment with the social health care services within the and possible contract termination. competence of the municipalities, implement- The procedure for choosing the general man- ing the agency strategies as formalized in the ager, which does not call for any comparative territorial health Plan drawn up in agreement evaluations, stresses the private features of the with the municipalities of the district. The size intuitus personae in keeping with the fiduciary of the district is regulated by the Regional indi- nature of the relationship. Provision is also cations referred to in Article 2, but may not in made for terms within which the appointment any case be smaller than 60 000 inhabitants; it must be made, and once these have lapsed, the may, however, be subject to some overriding substitutive powers specified in Article 2, geomorphological and population density char- para.2-nonies are applied. acteristics of the territory. The district manager, The norm also vests in the Region the responsi- a fiduciary appointment by the general manag- bility of defining – within the limits of the bud- er and an essential figure linking up with the get constraints both the general evaluation cri- Local Health Unit Agency, may avail him- or teria and specific objectives in terms of health herself of a coordination office to integrate the and service functionality – that have to be peri- district activities with those of the services and odically assigned to each director general. the departments into which the agency is divid- Paragraphs 7-15 regulate the employment rela- ed for organizational purposes. tionship of the general manager and the The district, therefore, represents both an oper- hypothesis of the termination of his contract ational structure for the provision of services ahead of time, making provision, as requested relating to basic and specialist outpatient care by the delegation principles, for the interven- and the promoter of projects for health that are tion of the local authorities both in the assess- of interest to several operational structures, ment procedure and the revocation procedure. including those of the municipalities in which The Article 3-ter defines the tasks and the roles are part of these projects for socio-health inte- of the old Board of Auditors known as Collegio gration purposes. dei revisori, which replaces the new Board Article 4 of Legislative Decree No. 229/1999 known as Collegio sindacale as the control redefines the criteria for the constitution of the organ of the Agency. units into Hospital Agencies, by applying the Article 3-quater contains the first organic and directive principles and criteria set out in Article systematic definition of the role and the func- 2, clause ii), of Law No. 418/1998 regarding the tions of the district as the operational organiza- identification of the “minimum organizational tion of the Local Health Unit Agency. This has characteristics and the national or interregional the function of ensuring accessibility, continuity importance of the hospital Agencies”. It estab- and timeliness of the health care response and lishes that the following can be constituted or to facilitate an intersectoral approach to health confirmed as Agencies: Health Cure Institutes promotion, ensuring integration health assis- of a Scientific Character, with the procedural tance with social assistance, in particular. and organizational features provided for by the Alongside the function of producer of services implementation regulations of Article 11, within the frame of primary health care, by para.1, clause d), of Law No 59 of 15 March means of organizational structures which 1997; the Agencies referred to in Article 6 of include general medicine doctors and paediatri- Law No. 419 of 30 November 1998, without cians freely chosen by each individual, the dis- prejudice to whatever may be disciplined on the trict assumes a government role for integrating occasion of the implementation of delegated Italian health service reform - 289

legislative power provided for this purpose as connection with the relationship between well as hospital agencies of national or interre- Regions, universities and structures of the gional importance. Other structures which can National Health Service. First of all, it is estab- similarly be constituted or confirmed as agencies lished that interministerial Decrees should peri- are hospital units organized into departmental odically (every three years) draw up specific form and provided with an economic asset and guidelines for entering into memoranda of accounting system based on cost centres in understanding and determining of the criteria which there are at least three operational units and parameters for the identification of the uni- that are qualified as highly specialized and are versity structures for carrying out health care equipped with second-level emergency depart- activities, specialist training and for university ments (although in this connection specialized diplomas. A transitory provision regulates the hospitals are an exception to this). The qualifica- period between the coming into force of the tion of the national or interregional valency of present legislative decree and the issue of the the Agencies provided for by the delegation is measures provided for by Article 6-bis with ref- further defined in operational terms on the basis erence to, respectively, the decrees of the Min- of a 20% higher admission frequency of patients istry of Health and the Ministry of the Universi- from other Regions compared to the average of ties and Scientific and Technological Research of the Region in which the unit is situated, and a 31 July 1997 and of the Ministry of the Universi- complexity index of the admitted cases which is ties and Scientific and Technological Research of 50% greater than the Regional average. 17 December 1997 and 24 September 1997. Nothing has changed regarding the procedural Article 6-ter regulates the criteria determining aspects associated with the recognition of the the need for health personnel operating in the hospital agency character, although the decree services and the structures of the National Health establishes a maximum period of three years Service for the sole purposes of enabling the within which the units currently constituted as Ministry of the Universities and Scientific and hospital agencies that do not satisfy the new cri- Technological Research to establish admission teria are to return to direct management by the criteria to degree courses, specialist training competent Local Health Unit Agency. schools and university diploma courses, as well Article 5 of Legislative Decree No. 229/1999 as the criteria on the basis of which training amends Article 5 of Legislative Decree No. 502 needs are to be distributed among the Regions of 30 December 1992, establishing norms and the self-governed Provinces in relation to regarding the cost-effective management of the existing potential. Local Health Unit Agencies and the hospital Article 7 of Legislative Decree No. 229/1999 Agencies and adds Article 5-bis to the aforesaid redefines the role of the prevention department decree; in order to simplify the procedures, this set up by the Regions, which in actual fact is the article makes provision for and regulates the operational structure of the Local Health Unit possibility of entering into programme agree- Agencies. Its functions are to be integrated with ments between the Ministry of Health, Regions those of the other operational Agency structures and Local Authorities for the construction of and, in particular, with the district activities. In health care facilities referred to in Law No. 67 of fact, the interventions of health promotion and 11 March 1988. illness prevention require the following: articula- Implementing the principles and criteria of dele- tion of the objectives; a high intervention com- gated legislative power set out in Article 2, plexity on the basis of the principle of assistance clause v), of Law No. 419/98, Article 6 supple- continuity; complementarity of the resources ments Legislative Decree No. 502 of 30 Decem- and the capacity of the operational structures to ber 1992 with Article 6-bis and 6-ter, which carry out common projects in a synergistic man- complete the regulations therein provided in ner. By applying organizational criteria that 290 - Italian health service reform

respect the principles of responsibility and purposes of attaining the assistance objectives strengthen them through the identification of agreed at the district level. Furthermore, the new organizations by functional areas, the article principles encourage medical partnerships within maintains the specificity of the interventions and the frame of the conventional relationships with the unitary nature of the structure, identifying general medicine doctors and paediatricians freely functional areas that correspond to the principal chosen by each individual with a view also to intervention sectors of the prevention depart- ensure health care continuity. ment, thereby providing the Region and the The additional Articles 8-bis and 8-octies devel- agencies with ample flexibility margins in rela- op the system of authorizations, accreditation tion to the local peculiarities and the organiza- and contractual agreements, and define the tional innovation features. remuneration criteria of the service-providing This flexibility is dictated not only by the need for structures and the system of controlling the respecting the organizational autonomy of the appropriateness and the quality of the services Agencies, but also by having to allow for the dif- provided. ferent degree of implementation of structures Regulation of the entry of public and private such as the Regional Agencies for the Environ- structures into the system providing services and ment (ARPA), which are outside the National benefits on behalf and at the expense of the Health Service and yet strongly integrated with INHS is articulated into three logically and proce- its activities, even though they do not necessari- durally distinct levels that are oriented to the ly substitute all the services that were previously pursuit of different objectives requiring the inter- within the competence of the former Multiareas vention of different institutional competencies: Hygiene and Prevention Laboratories and possi- authorizations for the establishment and func- bly Experimental Zooprophylactic Institutes. To tioning of the health structures, institutional this end, Articles 7-quinquies, sexies and octies accreditation and contractual agreements. lay down the norms to achieve the necessary Authorization to set up new health structures integration between the activities of the Preven- (provided for by Article 2, clause dd) of Law No. tion Department and, respectively, the ARPAs, 419/98) requires that municipalities, when exer- the Experimental Zooprophylactic Institutes and cising their competencies in this matter, should the Employment Inspectorates. Lastly, in as much first obtain from the Region an assessment of as the department is responsible for interven- the compatibility of the new structure with over- tions of considerable specificity, provision has all needs as well as the functionality of its terri- been made for an extension of its activities also torial collocation. into the areas of competence of the peripheral The authorization to carry out health-related offices of the Ministry of Health. activities represents the necessary condition that Article 8 of Legislative Decree No. 229/1999 re- makes it possible to provide services. The autho- determines the principles for the definition of the rization to carry out health-related activities is conventional relationships with general medicine granted to structures in possession of the mini- doctors and paediatricians freely chosen by each mum structural, technological and organization- individual, orienting them towards a system al requisites necessary to ensure the safety and based on primary treatments. They redefine the efficacy of the health care services provided. structure of the doctor’s remuneration, making These requirements are defined by the Region by provision for a lump sum for each assisted person, implementing the principles and criteria set out a variable component related to the attainment of in the act of orientation and coordination adopt- health, activity and expenditure objectives, as well ed in agreement with the Permanent as another component linked to the execution of State/Regions Conference, also with a view to specific services, identified as part of the conven- ensuring uniformity at the national level, and tion inasmuch as they are instrumental for the does not imply recognition that the party con- Italian health service reform - 291

cerned forms part of the structures providing tariffs associated with each service and the services on behalf of the INHS. financing of specific activity programmes, which Institutional accreditation is granted by the the decree indicates in detail. Region on the basis of the verification of two The contractual agreements thus have the func- elements: 1), possession of further qualification tion of selecting the accredited operators, defin- requisites of the structure as regards both the ing the volumes and the typology of the neces- organizational characteristics and the availability sary services, budgeting their overall remunera- of technological equipment and personnel and tion, and specifying the characteristics of the ser- the activities effectively carried out and the vices rendered as well as the controls that the results obtained; and 2) the functionality of the structure accepts to undertake with a view to structure with respect to regional planning, in checking the appropriateness and the quality of terms of the overall need and integrability into its services. the regional service network. Article 9 of Legislative Decree No. 229/1999 The guiding principles and criteria on the basis of replaces the present Article 9 of Legislative which the Regions define these further requisites Decree No. 502/1992 and establishes the essen- and grant the title of accredited structures to the tial lines for reorganizing the supplementary authorized structures that make the request are forms of health assistance in the implementation therefore disciplined by an act of orientation and of Article 2, para.1, clause cc), of the “Legge coordination agreed upon with the Permanent Delega”. The provision defines the supplemen- Conference on the Relationships between Cen- tary funds of the INHS as being additional bene- tral Government and the Government of the 21 fits, i.e. over and above the essential assistance Regions and Antonomous Provinces, which is levels defined by the INHP and however inte- based on the principle of parity between public grated with them, provided by the accredited and private providers. providers with whom appropriate agreements The character of accredited structure does not have been entered into as provided for by Article confer the right to perform health care related 8-quinquies. Other objects of the supplementary activities paid for by the INHS. The Regions and funds of the INHS are the benefits comprised Local Health Unit Agencies may choose from within the uniform and essential health care lev- among all the accredited providers structures, also els and the full range of socio-health services, for by means of comparative assessment of the qual- which the costs must be borne by the persons ity and the cost of the services offered, the public, receiving assistance. private non-profit and private commercial struc- The definition of the benefits exceeding the tures with whom they wish to enter into contrac- essential health care levels calls for a greater level tual agreements that give the right to provide of specification and the present norm therefore health care related services paid for by the INHS. refers indication of the specific forms of assis- The contractual agreements entered into tance and the benefits associated therewith that between Region, Local Health Unit Agency and are to be covered by the supplementary funds of accredited structures represent the final stage of the INHS to a subsequent decree of the Minister the process of identifying the providers deliver- of Health after having heard the opinion of the ing guaranteed services on behalf of and paid Unified Conference as provided for by Article 8 for by the INHS. These agreements are to define of Law Decree No. 281/97. the activity programme of each structure with a As a temporary measure, the discipline of the view to producing and distributing the services supplementary funds of the INHS is also extend- and the benefits necessary and appropriate to ed to thermal spa water treatments, though only attaining the objectives defined by national and in respect of services not paid for by the INHS, regional planning, as well as the estimated over- and to dental care, with the exclusion of preven- all funding, calculated on the basis of both the tion programmes during childhood and assis- 292 - Italian health service reform

tance to specific categories of persons in condi- medical and health research - the needs of which tions of particular vulnerability. are to be specified by means of an appropriate The new provision lays down the general princi- research programme - related to the cognitive and ple of self-management and, in implementing operational needs of the INHS, financed by means the principles of the “Legge Delega”, establish- of a tied share of the National Health Fund. The es the possibility for the Regions, Self-governed programme is to be drawn up by the Minister of Provinces and local authorities to participate in Health after consultation with the National Health managing the funds. Other aspects regarding Research Commission, which also has the task of the fund regulations (i.e. modalities to set up proposing initiatives to be included in the planning and devolve funds; constitution and disband- of national scientific research (provided for by Leg- ment modalities; forms of contribution; benefi- islative Decree No. 204 of 5 June 1998) and in ciaries of the assistance and frame of the guar- international and Community research. The pro- antees of the underwriters) will be the object of gramme is to be adopted by the Minister of Health a subsequent regulation to be issued upon a in agreement with the Permanent Conference on proposal of the Minister of Health. the Relationships between the Central Govern- Article 10 of Legislative Decree No. 229/1999, ment and Governments of the 21 Regions and which replaces Article 9-bis of Legislative Decree Autonomous Provinces within six months of the No. 502/92, redefines the frame of management coming into force of the INHP, which has a three- experimentation and lays down appropriate year duration and is financed by means of tied implementation modalities. shares of the National Health Fund. The provisions focus the frame of such experi- Article 12-bis of Legislative Decree No. mentations on “new management models that 229/1999 also makes a distinction between cur- call for collaboration between components of rent research activities and those of targeted the INHS and private sector institutions, also research. The former concerns the setting up of through the setting up of joint stock compa- the institutional projects of the research bodies nies”, while the general end remains that pro- approved by the Ministry of Health, while the lat- vided for by Legislative Decree No. 502/92, i.e. ter concerns the achievement of specific objec- the evaluation of these management forms in tives considered to merit priority by research terms of convenience, improvement in health organizations. care quality and the elements guaranteeing Provision has been made to involve the Regions assistance guaranteed to the citizens. in compiling the National programme, both dur- The new article makes provision for the Regions ing the phase of formulating proposals and in concerned to propose specific programmes that bearing responsibility for the carrying out indi- define the functions and the respective obliga- vidual applied projects, as well as in implement- tions of all public and private providers taking ing a monitoring system for the purpose of veri- part in the experiment, excluding, however, any fying the results obtained and transferring them form of contracting or subcontracting, as well as into health care activities. forms of terminating contracts in the case of Paragraphs 9 and 10 make provision for estab- non-fulfillment or when the Permanent lishing the National Ethics Committee and ethics State/Regions Conference, which has the task of committees within each health Agency (see also supervising the experiment and assessing its out- Chapter IX). comes, states that the objectives pursued by the Reformulating the present Article 15 of Legisla- said experimentation have not been attained. tive Decree No. 502 of 30 December 1992 and Article 11 of Legislative Decree No. 229/1999 adding to it the various articles from 15-bis to adds Article 12-bis to Legislative Decree No. 15-undecies, Article 12 defines health system 502/92. This regulation requires the INHP to define management, making provision for it to be sub- the general ends and the priority sectors of bio- divided into professional management and man- Italian health service reform - 293

agement which will also have structural man- to which responsibilities of managing human, agement responsibilities. Health management, technical or financial resources are attributed by disciplined by Legislative Decree No. 29 of 3 Feb- the Agency, ensure greater flexibility in employ- ruary 1993, is characterized by technical and ing managers. The modalities of the contracts professional autonomy and the gradual widen- for a limited period of time which, in accordance ing of the scope of this autonomy. with the guiding principles and criteria contained Provision exists for the institution of a single in the ”Legge Delega”, the health Agencies may health management level which is deemed to be enter into for the carrying out of management more consistent with the principle affirmed in functions of particular importance or strategic the “Legge Delega” (Article 2, para.1, clause p)) interest or for acquiring professional services and also with the evolution of legislation in the from experts of proven competence or for train- public employment sector. The system of collec- ing and employment contracts for targeted pro- tive bargaining regulates both the exclusive jects likewise tend towards this direction. employment relationships with the health man- Lastly, provision is made for lowering the pen- agers and the pensionable age in the case of sionable age of medical personnel employed by personnel under contract. the INHS to sixty-five years, although this may be Irrespective of whether they have an employ- raised to sixty-seven years according to the pro- ment contract for a limited or an indeterminate visions of Legislative Decree No. 502 of 30 period of time, health managers whose contract December 1992, while the university personnel was entered into or renewed after 31 December referred to in Article 102 of Presidential Decree 1998, as well as those who at the time of the No. 382 of 11 July 1980, albeit limited to health coming into force of the law decree opted to care activities and the management of health perform intramural activities as self-employed care structures, must retire from these functions professionals, will henceforth be subject to an on reaching the age of sixty-seven years. exclusive employment relationship. Article 15-decies of Legislative Decree No. The choice in favour of an exclusive employment 229/1999 provides for the obligations in con- relationship is irrevocable, because it is designed nection with regulations to be extended also to to be the sole type of relationship which hence- doctors working in hospitals or other hospital- forth will characterize health management. The ization and treatment structures of the INHS. collective employment agreement has also the Article 15-undecies of Legislative Decree No. task of arranging matters so that the character- 229/1999, which concerns personnel mobility, istics of an exclusive employment relationship extends the application of Article 25 of Presiden- will be such as to ensure the coming into force tial Decree No. 761 of 20 December 1979 to and further development of professionalism and mobility between public structures, classified as appropriate financial reimbursement. hospitals and vice versa, and private-law hospi- Collective employment agreements have the tals and clinics of a scientific character that have task of determining the additional financial ben- brought their personnel regulations into line efits to provide incentives for choosing such an with the provisions of the present decree. exclusive relationship and regulating the imple- Implementing Article 2, para.1, clause v), of the mentation modalities for working as a self- “Legge Delega”, Article 13 adds the Articles 16- employed professional as well as the other activ- bis to 16-sexies to Article 16 of Legislative ities that the Agencies wish to guarantee by Decree No. 502 of 30 December 1992. Article granting forms of income sharing to the profes- 16-bis provides the definition of continuous sional men and women who perform these training and professional development for the activities outside their normal service duties. personnel of the INHS, while Articles 16-ter The new modalities for appointing management makes provision for establishing a National Com- positions, i.e. organizational structures according mission for Continuous Training with the task of 294 - Italian health service reform

defining the training goals of national concern, National Commission for the Accreditation and paying particular attention to the compiling, dis- the Quality of the Health Services, set up with- seminating and adopting of guidelines and asso- in the Agency for the Regional Health Services. ciated diagnostic and therapeutic approaches. Its organization and functioning modalities are Article 16-quarter of Legislative Decree No. laid down in an appropriate regulation adopt- 229/1999 regulates the various forms of incen- ed by the Minister of Health in accordance with tives of continuing education. Article 16-quin- Article 17, para.1, of Law No. 400 of 23 quies regulates managerial training as the August 1988. The Commission, which is to necessary condition for assigning health man- consist of 30 experts of proven experience in agement posts and also for second-level man- the sectors of organization, management and agement in the health sector. Article 16-sexies the assessment of health services, research and sets out the modalities for identifying the hospi- bioethics, has the task of certifying the opera- tal units, the district structures and the depart- tors and associations that intend to perform ments which comply with the requirements of accrediting activities for health structures and the National Commission for Continuous Train- compiling guidelines. It is also to promote and ing and which can therefore be entrusted with monitor the activities carried out at the Region- teaching functions for the training and develop- al level. ment of health personnel. The task of identifying the modalities and the Article 14 of Legislative Decree No. 229/1999 instruments for verifying the implementation of replaces Article 17 of Legislative Decree No. 502 the accreditation model is assigned to the of 30 December 1992 which disciplines the Regions, with an annual report to the aforemen- management board and adds to it Article 17-bis tioned National Commission of the results of the concerning the departmental organization as activity performed in connection with the moni- the ordinary operational management model for toring of the state of implementation of the all the activities of the health Agencies. accreditation system. Although its activities and composition are to be Article 19-ter regulates a system of comple- overseen by each individual Region, the manage- mentary interventions to ensure the functionali- ment board is a body of which the General man- ty and the efficacy of the INHS. ager avails himself for governing clinical activities, In this sense the network comprising the Min- compiling the activity programme of the Agency, istry of Health - Agency for the Regional Health organizing the health care services, implementing Services - Regions is activated in function of the the departmental model and for planning and collection of significant data, their evaluation assessing the technical and health activities as and any necessary measures for eliminating mal- well as the activities of full health integration. functioning situations from the system. In turn, the departmental organization of the Article 19-quarter requires the various bodies Agency structures constitutes the principal orga- and commissions provided for by the Decree to nizational innovation measures introduced by avail themselves exclusively of the pre-existing the decree for the purpose of strengthening structures and personnel of the Administrations management and professional responsibilities. in which they operate, thus ensuring that their Indeed, the Department is identified as the cen- functioning will not cause any additional bur- tre of responsibility both from the economic dens for public spending. point of view and, above all, as regards the com- Article 19-quinquies, lastly, provides that the pilation of programmes of activity and for the Minister of Health is to report to Parliament each systematic and continuous assessment of the year on the trend of health expenditure, paying quality of the health service provided. particular attention to the financial impacts Article 15 of Legislative Decree No. 229/1999 directly related to the new measures introduced adds Article 19-bis, which regulates the by the Decree. CHAPTER XVI

METHODS AND DATA SOURCES

CONTENTS

1. METHODS ...... 296

2. DATA SOURCES ...... 296 296 - Methods and data sources

1. METHODS easily accessible through the Internet (e.g. infectious diseases); In order to facilitate data presentation, a con- • the comparisons among different countries sistent approach has been adopted throughout (as well as among different areas within the Part I of the present Report, including: same country) of data on a wide range of • a description of the current Italian health sta- health outcomes and risk factors require stan- tus (most recent available data); dardisation in the definition of indicators. • a comparison of the current Italian situation To make the comparisons as valid as possible with those of other European Countries; for each indicator, data from one common • a comparison of the current situations among international source (e.g. WHO HFA database, different areas of Italy, in view of the hetero- OECD, IARC publications, etc.) have been used, geneity of Italian Regions; assuming that they have been collected in a • a description and analysis of time trends (both consistent way. However, there are other fac- among Italian jurisdictions and among Euro- tors operating at the local level (such as case pean countries). ascertainment, recording and classification Temporal trends of certain health or risk factor practices as well as cultural and linguistic differ- indicators for different European countries have ences) that can impact data validity. been used for a direct comparison of the most In the absence of routinely collected data, other recently available data as well as of the changes valid sources such as the results of ad hoc stud- over time among countries. When available, ies have been considered if published in peer the average European value of each indicator reviewed journals or reported in International has been added. Furthermore, a calculation of conferences. However, comparisons of data the change over time (usually comparing the from these studies, particularly if employing dif- most recent 10-year period) has been reported ferent methodologies, should be interpreted in order to provide some understanding of the with caution. feasibility of achieving the HEALTH21 targets and/or the goals proposed by INHP 1998-2000. The main sources of data used in this report are 2. DATA SOURCES presented in detail in the next section and the complete list of references is reported at the One of the main sources of data used in this end of this volume. report is the WHO Health for All Database, Given that proper information on health status, (February 1999 version, with 1993 Italian mor- risk factors and health service organization is tality data) from the WHO Regional Office for crucial, it is stressed that: Europe. This large database has been in opera- • the availability of some epidemiological data, tion since 1984 and is based on the agreement at least at the national level, is not fully satis- among WHO Member States to use and report factory at the time of the finalization of this a common set of global and European HFA indi- report (June 1999) and the most recent avail- cators. Although data collection in individual able Italian mortality data refer to 1994; countries can still be improved, the database • for some health indicators (particularly those provides numerous indicators (demographic, referring to the incidence and prevalence of mortality, morbidity and some health-related chronic diseases, health risk factors and the risk factors) from the WHO European Member quality of health care), official National data are States. It must be stressed that the mortality still lacking or very poor. Accessibility to data is data included in the database are standardised difficult, even though they are routinely collect- to the European population. Therefore, the ed (e.g. air pollution data). Only recently have Standardised Death Rates reported from this some routinely collected data been made more source are not directly comparable with those Methods and data sources - 297

reported from other sources (ISS for instance, Much information (particularly relating to see below) which have been standardised to inequalities in health and environmental risk the Italian population. factors) has been obtained from the 19976 The Health for All Database can be downloaded WHO-ECEH report “Ambiente e salute in free of charge from the WHO web site Italia”, and updated with the most recent avail- http://www.who.dk. able data (e.g. air pollution, bathing water, Most indicators related to medical resources, etc.). health expenditure and funding, costs and Most of the Italian data on accidents and on financial flows have been taken from the OECD the prevalence of chronic diseases have been (Organization for Economic Cooperation and obtained from the Ministry of Health’s Development) database published in 1998. The “Relazione sullo stato sanitario del paese OECD Health Data is an interactive database 1996” as well as from the report Highlights on comprising systematically collected data on Italy – WHO, 1998. numerous key aspects of the health care sys- The data on the Italian National Health Service tems in the 29 OECD Member countries within come from the Health Information System of their general demographic, economic and the Ministry of Health based on the Information social contexts. flows of Local Health Agencies and Hospital Some demographic data, data on the preva- Agencies for the year 1997. lence of some health risk factors (such as Data on infectious diseases in Italy have been tobacco smoke) and on prevalence of some taken from the ISS which collects data from chronic health diseases in Italy have been gath- the National routine infectious diseases regis- ered from ISTAT (National Institute of Statistics) tration system. Data on a number of notifi- periodical demographic publications, from able infectious diseases for the period 1993- ISTAT thematic publications (e.g. on road traf- 1996 are available from the Ministry of Health fic accidents, abortion) and from ISTAT Nation- web site (Malinf Epidemiological Bullettin al surveys (multipurpose surveys on families, http://www.sanita.inerbusiness.it/malinf/eng- various years). It is stressed that the ISTAT lish/bollepid/index.htm). National Survey has some limitations related to Data for the report have also been gathered the methodology used (questionnaires submit- from a few specific surveillance systems operat- ted to a sample of Italian families; one ques- ing in Italy: tionnaire for each head of family). In this way, • The AIDS surveillance system coordinated by accurate data, for instance on the prevalence the Centro Operativo AIDS of the ISS (COA – of smoking, are actually reliable only for the ISS), which has been operating since 1987; person who directly completed the question- • The national surveillance system for sexually naire and may be questionable, for instance, in transmitted diseases (STD) coordinated by COA relation to adolescents. Furthermore, data on – ISS. This system has been active since 1991 chronic diseases and disability are taken only and is based on the reporting of newly diag- from the questionnaire, without any clinical nosed STDs, from 43 public health clinics (STD examination or confirmation from medical Surveillance Centers) located in 18 (out of 20) records. Italian Regions. Data reported in this document Mortality data presented for the main Italian refer to the year 1995 when data were report- areas are based on the routinely collected mor- ed by 38 of the 43 STD Surveillance Centers; tality data (ISTAT) that are available only up to • The SEIEVA surveillance system for type-spe- 1994, as noted above. The National Institute cific acute viral Hepatitis. This system was devel- Health of has kindly supplied the data stan- oped in Italy in 1985. SEIEVA is coordinated by dardised to the Italian population for the period the ISS in collaboration with local health dis- 1970-1994 and for the major Italians areas. tricts. Since 1992, the health districts partici- 298 - Methods and data sources

pating in the surveillance system have been dis- Data on cancer incidence in the European tributed throughout the country and have countries are based on figures published by included about 40% of Italian population. IARC (International Agency for Research on Epidemiological data on AIDS in the EU coun- Cancer-WHO) Scientific Publication no. 143 tries are available from the European Centre “Cancer Incidence in Five Continents”, 1997. for the Epidemiological Motoring of AIDS – Statistics on the five-year survival of cancer CESES (WHO-UNAIDS-EU Collaborating Cen- patients have been obtained from the IARC tre), and retrievable from the Internet at The studies EUROCARE (IARC Scientific Publication fallowing address: http://www.ceses.org. No. 132, 1995) and the ITACARE study (Verdec- Data on immunization coverage in Italian chil- chia et al, Survival of Cancer Patients in Italy. dren are based on the results of a specific sur- The ITACARE study. Tumori, 1997). vey named ICONA and coordinated by ISS in International data on Occupational Diseases 1998. ICONA is a series of regional surveys con- and Accidents have been gathered from the ducted simultaneously between January and International Labour Office (Yearbook of March 1998 in 19 of Italy’s 20 Regions. Cluster Labour statistics, 1998 ILO-BIT 1998), whereas sampling according to the methodology of the national data have been provided by the ISPESL. WHO Expanded Programme of Immunization Data on the frequency of Congenital Malfor- was conducted in 18 Regions, whereas simple mations have been mainly obtained from the random sampling was conducted in 2 main EUROCAT project (European Registration of cities (Milan and Naples) and in one Region Congenital Anomalies, Report No. 7, 15 Years with less than 1 000 newborns per year. Immu- of Surveillance, Scientific Institute of Public nisation coverage was calculated for all children Health, Louis Pasteur, Bruxelles, 1997) included in the survey for each of three doses Data on drug use and traffic accidents have of polio, DT, whooping-cough and hepatitis B been obtained from the report “La salute in vaccines. Coverage was calculated for HIB Italia”, 1997, and updated with most recent immunisation and included children immunised data obtained from the Ministry of Health and with three doses by the first year of life as well from ACI (Automobil Club Italiano), 1999. as children immunised with only one dose after International mortality data for accidents in one year of age. The vaccination coverage for childhood have been obtained from a recently measles was calculated only for children aged – completed review of WHO mortality data at least 16 months at the time of interview. The (London School of Hygiene and Tropical Medi- study population included 4 310 children over- cine – WHO European Centre for Environment all. The cluster sampling method used implies and Health: Childhood injuries – A priority area an error margin of approx. 10%. Data reported for the transition countries of Central Europe referto immunisation coverage in the first two and the Newly Independent States – Final years of life. (ISS: “ICONA: Indagine sulla cop- Report. September 1998). ertura vaccinale infantile, 1998”). The prevalence of allergic disorders has been Data on cancer incidence and prevalence in obtained from the European Allergy White Italy are based on data from the existing Ital- Paper published by the UCB Institute on Aller- ian Cancer Registries. These figures have been gies, and from the results of the ISAAC and recently summarised in the comprehensive SIDRIA studies. The ISAAC study (International report “Fatti e cifre dei tumori in Italia”, 1998. Study of Asthma and Allergies in Childhood) There are at present 13 Cancer Registries in was conducted in 56 countries, with a total of Italy covering areas with a total of about 8 more than 700 000 children participating. It million people (about 15% of the whole pop- was specifically designed to permit compar- ulation), mainly located in Northern and Cen- isons of asthma and allergies in childhood tral Italy. between populations in different countries. The Methods and data sources - 299

SIDRIA study (Studi Italiani sui disturbi respira- laboratory and diagnostic tests) followed by a tori nell’infanzia e l’ambiente) represents the second phase consisting of the clinical examina- Italian extension of the ISAAC study; it was tion of suspected cases by a specialist. Table aimed at estimating the prevalence of respira- XVI.1 shows the prevalence rates, unreported tory disorders in children and at investigating cases and false positive cases (i.e. self-reported the role of several potential risk factors. The cases not clinically confirmed) by sex from this SIDRIA study was conducted in 1994-1995 in study. According to these results, the authors 10 centres of Northern and Central Italy, vary- concluded that self-reported information can ing in size, latitude, climate and level of urban- lead to inaccurate estimates of prevalence rates, isation. More than 40 000 randomly selected thus suggesting the need to include the clinical children (aged 6-7 years and 13-14 years) par- evaluation in any population-based epidemio- ticipated in the study. logical study. This may be relevant in the assess- Estimates of smoking habits among adoles- ment of data on chronic disease prevalence cents aged 13-14 years (obtained through a derived from interview surveys. self-administered questionnaire) and among Parte II of the present Report is essentially an parents of children and adolescents resulting English version of the Italian National Health from the SIDRIA study have also been included. Plan enforced in the Presidental Decree of 23 Some data on the prevalence of chronic diseases July 1998 (published in the Supplemento Ordi- in the elderly have been taken from the ILSA nario alla Gazzetta Ufficiale del 10 Dicembre study (The Italian Longitudinal Study on Ageing) 1998, No. 228) and an explanation of Law No. 1992-1993. This study aimed to evaluate the 419/1998 conferring delegated legislative rates of some chronic diseases (diabetes, cardio- power for the reform of the Italian National vascular and neurological disorders) in a random Health Service as well as of the Legislation sample of 5 632 Italians aged 65-84 years. The Decree No. 299/1999 implementing this dele- study had a first screening phase for all sampled gation for the Italian National Health Service participants (interview, physical examination, Reform. 300 - Methods and data sources

Table XVI.1.: Prevalence ratesa (%) of clinically confirmed cases, unreported cases, false positive cases, (i.e. self-reported cases not clinically confirmed) by sex; population 65-84 years of age. The Italian Longitudinal Study on Ageing (ILSA) 1992-1993.

PREVALENCE UNREPORTED FALSE POSITIVE RATE CASES CASES WOMEN MEN WOMEN MEN WOMEN MEN

CARDIOVASCULAR SYSTEM Myocardial infarctionb 4.8 10.7 2.3 3.1 3.4 3.6 Angina 6.9§ 7.8 2.6 3.2 0.9 0.9 Arrythmiab 20.3§ 25.1§ 6.7§ 9.8§ 6.5 4.7 Congestive heart failure 7.3§ 5.4§ 4.1§ 3.0 2.6§ 3.0 Coronary Artery diseasesb 5.2 8.1 1.7 2.8 7.1 4.4 Hypertensionbb 67.3 59.4 17.7§ 22.3 2.4 2.1

ENDOCRINE SYSTEM Diabetes mellitus 13.4 12.9 1.0 1.6 4.0 4.1

NEUROLOGICAL SYSTEM

Stroke 5.9§ 7.4§ 1.1 1.5 2.2 3.5 Dementia of any typeb 7.2§ 5.3§ 0.4 0.5 0.8§ 0.8 Parkinsonism 3.0§ 3.0§ 1.3§ 1.2§ 0.4 0.3 Distal symmetric 6.5§ 6.5 5.8§ 5.7 1.9 1.4 neuropathy of lower limbs

a Adjusted to the Italian population 1991 b Significant difference between men and women in the prevalence rates, p<0.01 § Significant age trend, logistic regression, p<0.05

Source: ILSA, 1997. ANNEXES

LIST

Annex 1 WHO Collaborating Centres in Italy ...... 302 Annex 2 Istituto Superiore di Sanità (National Institute of Health) ...... 305 Annex 3 Istituto Superiore per la Prevenzione e la Sicurezza del Lavoro (National Institute for Prevention and Safety at Work) ...... 310 Annex 4 Agenzia per i Servizi Sanitari Regionali (National Agency for Regional Health Care Services) ...... 312 Annex 5 Training activities carried out by some IRCCS as of 1996 ...... 313 Annex 6 Training activities carried out by some Regions and Autonomous Provinces ...... 318 Annex 7 Research Activities of the IRCCS as of 1996 ...... 320 Annex 8 Declaration of the Third Ministerial Conference on Environment and Health (London, 18 June 1999) ...... 323 Annex 9 Law 30 November 1998, No. 419, Delegation to the Government for the streamlining of the National Health Service and the adoption of a Consolidation Act regarding the organization and functioning of the National Health Service. Amendments of Law Decree No. 502 of 30 December 1992 ...... 336 Annex 10 Consiglio Superiore di Sanità (National Health Council) ...... 344 Annex 11 General data about Italy ...... 345 302 - Annexes - 302

ANNEX 1: W.H.O. Collaborating Centres in Italy1 COMMUNICABLE DISEASES

INSTITUTION COLLABORATION TOPIC DIRECTOR ADDRESS CITY Università di Roma* Genetics and Ecology of Mosquito Vectors Prof. M. Coluzzi Piazzale delle Scienze, 5 Roma Istituto Superiore di Sanità Streptococci & Streptococcal Infections Dr G. Orefici Viale Regina Elena, 299 Roma Istituto Superiore di Sanitàa) Reference & Research on Poliomyelitis Dr L. Fiore Viale Regina Elena, 299 Roma Istituto Superiore di Sanità Communicable Diseases Surveillance Dr D. Greco Viale Regina Elena, 299 Roma Istituto Superiore di Sanità Arbovirus Reference & Research Dr L. Nicoletti Viale Regina Elena, 299 Roma Istituto Superiore di Sanità Human Resources & Educational Technology Prof. G. Majori Viale Regina Elena, 299 Roma Development for Control of Tropical Diseases DISADVANTAGED PEOPLE

INSTITUTION COLLABORATION TOPIC DIRECTOR ADDRESS CITY Istituto Burlo Garofolo Maternal & Child Health Dr A. Cattaneo. Via dell’Istria, 65/1 Trieste Ospedale “I Fraticini”* Healthy Ageing Dr A. Baroni Viale Michelangiolo, 41 Firenze EMERGENCY

INSTITUTION COLLABORATION TOPIC DIRECTOR ADDRESS CITY c/o OGCS/UTC Ministry of Emergency and Training of Socio-health Personnel Dr G. Carrino Piazzale della Farnesina, 1 Roma Foreign Affairsa) ENVIRONMENT

INSTITUTION COLLABORATION TOPIC DIRECTOR ADDRESS CITY Università di Torino* Environmental Epidemiology in Small Areas Prof. B. Terracini Via Santena, 7 Torino Università di Padova* Environmental Epidemiology Prof. B. Paccagnella Via Giustiniani, 3 Padova Ospedale Civico - USL 58 Prevention & Treatment of Burns and Fire Disasters Dr S.W.A. Gunn Via C. Lazzaro Palermo HEALTH PROMOTION / EDUCATION

INSTITUTION COLLABORATION TOPIC DIRECTOR ADDRESS CITY Istituto dell’Approccio Centrato Health Promotion at Work Dr A. Zucconi Piazza Vittorio Emanuele Roma sulla Persona Centro di Medicina del Turismo Tourist Health & Travel Medicine Dr W. Pasini. Viale Dardanelli, 64 Rimini Clinica del Lavoro “Luigi Devoto” Occupational Health Prof. R.Gilioli Via San Barnaba, 8 Milano Centro Studi Professioni Nursing Information, Documentation, Education Dr P. Lupano Via XX Settembre, 76 Torino Infermieristiche & Research Società di Ricerca Org. Sanitaria* Health Economics Prof. A. Brenna. Viale Antonio Gramsci, 22 Firenze Istituto Superiore di Sanità Problem-based Learning in Health Prof. G. D’Agnolo Viale Regina Elena, 299 Roma Professions Education

1 Based on a recent survey carried out by the Ministry or Health of Italy Annexes - 303 a ITY ITY ITY ITY C C C C IRECTORIRECTOR ADDRESS ADDRESS IRECTORIRECTOR ADDRESS ADDRESS D D D D NEUROSCIENCES MENTAL HEALTH MENTAL HEALTH SERVICE MANAGEMENT SERVICE HEALTH NON-COMMUNICABLE DISEASES Prevention of CVDs Prevention of CVDs Non-Communicable Diseases Education for Health Professionals OLLABORATION TOPIC OLLABORATION TOPIC OLLABORATION TOPIC OLLABORATION TOPIC C C C C PsichiatriaMentale Reg. F.V.G. Rehabilitation c/o Di.M.I.S.E.M. to the St. Vincent Declaration according NSTITUTION NSTITUTION NSTITUTION NSTITUTION ANNEX 1: W.H.O. Collaborating Centres in Italy (continued) Collaborating Centres ANNEX 1: W.H.O. I Fondazione Smith Kline di Studi Sanitari*Istituto Superiore Health and Ethics, Patient Rights HigherI Hospital ManagementUniversità di MilanoUniversità di Padova “Mario Negri”Istituto di Ricerche in Studi e Ricerche Centro G. Cannarella Prof. in Mental Health and Training Research Clinico Colle CesaranoCentro Università di NapoliOspedale Policlinico in Mental Health and Training Research Viale dell’Esperanto, 62 in Psychosocial Salute and Training Studi e Ricerche Research Centro Suicide Prevention in Mental Health and Training Research Rom in Mental Health and Training Research I Dr L. FratturaAss. Oasi Maria Santissima in Mental Health and Training Research Dr N. Raffa.Fondazione Int. Fatebenefratelli* in Mental Health and Training Research G. Racagni Prof. Ospedale Bufalini Dr C. Munizza A. Petiziol Prof. in Neuroscience and Training Research I in Neuroscience and Training Research 62 Via Eritrea, Rotelli Dr F. Università di Milano 9 Via Balzaretti, Corso Magenta, 59Azienda Ospedaliera S. Maria* Dr M. Maj Inferiore Via Maremmana M. Tansella Prof. Sangue Piazza del Donatore D. De Leo Prof. Rehabilitation Prevention, Neurotrauma in Rehabilitation and Torino & Training Research Tivoli (Roma) Dr C.L. Bolis Milano Milano Ayala Milano Via S. Cilino, 16 G.F. Prof. Epidemiology & Community Dentistry Largo Madonna delle Grazie 7 Via Vendramini, Napoli Servadei Dr F. Dr G. Molinis 73 Via Conte Ruggero, 12 Via San Vittore, Trieste Padova (En) Troina G. Vogel Prof. Milano 286 Viale Ghirotti, Via Gervasutta 48 Verona via Beldiletto, 1/3 Cesena Udine Milano Ospedale S. M. MisericordiaUniversità di TorinoUniversità di Cagliari* di Oncologia Istituto Europeo in Monitoring & Prevention & Training Research Università di RomaUniversità di Perugia* Statistical Modelling in Epidemiology of B. BonomiOspedale Maggiore Dr D. Vanuzzo of Diabetes-Related Blindness Prevention Diseases of Hereditary Community Control Inherited Coagulation Disorders in Diabetes of Quality Care Improvement Oral Health in Developing Countries Piazzale Santa Maria Boyle P. Prof. A. Cao Prof. M. Porta Prof. Udine Brunetti P. Prof. Via Ripamonti, 435 Via Jenner G. Goracci Prof. Corso A.M. Dogliotti, 14 Mannucci P.M. Prof. Via Enrico dal Pozzo Torino Milano Via Pace, 9 5 Piazzale Aldo Moro, Perugia Cagliari Roma Milano 304 - Annexes ITY ITY ITY ITY ITY ITY (Milano) C C C C C C IRECTORIRECTOR ADDRESS ADDRESS IRECTORIRECTOR ADDRESS IRECTOR ADDRESS IRECTOR ADDRESS ADDRESS D D D D D D NUTRITION PESTICIDES ONCOLOGY PREVENTION VETERINARY HEALTH VETERINARY TRADITIONAL MEDICINE OLLABORATION TOPIC OLLABORATION TOPIC OLLABORATION TOPIC OLLABORATION TOPIC OLLABORATION TOPIC OLLABORATION TOPIC C C C C C C dei Tumori of Melanoma Redesignation in progress. Agreement expired as of July 1999. expired Agreement NSTITUTION NSTITUTION NSTITUTION NSTITUTION NSTITUTION NSTITUTION ANNEX 1: W.H.O. Collaborating Centres in Italy (continued) Collaborating Centres ANNEX 1: W.H.O. I Istituto Nazionale per la Nutrizione NutritionI Università degli Studi di Pisa Cancro*Istituto N. Ricerche Istituto Italiano Studio e Cura di OncologiaIstituto Europeo Cancer of Thyroid Diagnosis & Treatment Primary Health Education Evaluation of Methods Diagnosis & Treatment I & Palliative Care Cancer Control Internazionale Centro Pesticidi* N. Cascinelli Prof. Health and Environment A. Pinchera Prof. I Istituto “Fernando De Ritis” 1 Via G. Venezian, Luzzi Dr A. Ferro I Via Paradisa, 2Università di Milano Viral Hepatitis L. Santi Prof. Ventafrida V. Prof. Milano I 546 Via Ardeatina, Istituto Zooprofilattico di SanitàIstituto Superiore Via Ripamonti, 435 Pisa M. Maroni Prof. Largo Rosanna Benzi, 10 Medicine Traditional * Roma a) Genova Milano Public Health in Veterinary & Training Research Epidemiology in Veterinary & Training Research Via Magenta, 25 G. Majori Prof. Caporale Dr V. G. Da Villa Prof. Busto Garolfo Viale Regina Elena, 299 Via Campo Boario CP 137 U. Solimene Prof. Via Generale Orsini, 42 Teramo Roma Napoli Via Cicognara, 7 Milano Annexes - 305

ANNEX 2: Istituto Superiore di Sanità (National Institute of Health)

The “Istituto Superiore di Sanità” (ISS) is the neurological disorders; cancers; infectious and main Italian Institute of scientific-technical parasitic diseases; metabolic, chronic-degenera- research, control and advice in public health. It tive and cardiovascular diseases; human genet- was founded in 1934 and since 1978 it has ics; blood; public health care and health ser- become the technical and scientific body of the vices; health and environment; radiation; food- Italian National Health Service. It is under the stuffs safety, nutrition and veterinary public authority of the Minister of Health, and has its health; quality assurance. own structures, particular rules and scientific The implementation of research and interven- autonomy. At present, the Institute comprises tion activities throughout the country, as well as 20 laboratories with a full back up of general pluriannual projects are promoted by the ISS and technical services (Figure 2.1). and financed by the Italian National Health It carries out various activities for the surveil- Fund. They include: blood; risk factors in moth- lance, control and promotion of public health: er and child health; development of proton use research; control and intervention; advice; con- for cancer therapy; organ transplantation; men- ferences, courses and publications. tal health; somatic gene therapy; tuberculosis, multiple sclerosis; viral hepatitis; Creutzfeldt- Research Jakob disease; information system for infectious diseases. The Institute collaborates with the Minister of Health in drawing up and implementing sci- Control and Intervention entific public health programmes. It promotes programmes of national relevance in accor- The Institute evaluates the quality and safety of dance with the objectives of the Italian newly produced drugs before their clinical National Health Plan in conjunction with experimentation on humans. It is also involved Regions, Local Health Unit Agencies, hospitals in: inspections, batch-releases and analytical and national and international institutions; it controls; sanitary investigations and surveys also develops research programmes on health nation-wide, specifically on air, water and and the environment and clinical experimen- workplace; batch-releases on vaccines, drugs, tation of national relevance in general and medical devices, food, chemical and diagnostic research hospitals. It participates in foreign aid, according to national and European Union and international research projects in the field regulations; sanitary technical investigations on of public health care, and in research works patients, technical projects and public and pri- and studies carried out by national institu- vate productive plants. The Institute controls tions. the public health activity of the Experimental It coordinates and finances national research on Zooprophylactic Institute; it performs technical AIDS, carried out both at the ISS and also by inspections on Italian Transfusion Centres and other national research institutes. on Centres authorized for organ transplanta- In 1997, three-year (1997-1999) research pro- tion. jects started dealing with the same main topics The Institute is responsible for certification or determined by the Italian National Health Plan notification of testing laboratories and notified and by the European Union biomedical and bodies established on the basis of European environmental research programmes, i.e.: Union regulations and international treaties in drugs; biomedical technologies; mental and the field of public health. It maintains, distrib- 306 - Annexes

utes and produces biological standards and energy (thermoelectric, nuclear, radioactive, upon request of the Ministry of Health, it pro- etc.) as well as with applications for diagnostic duces therapeutic, prophylactic and diagnostic and therapeutic purposes. substances. It draws up technical standards concerning, It compiles and updates the Italian National food, products, activities and works in the san- Inventory of Chemical Substances to be used in itary field; it also outlines up and updates stan- health evaluation connected with their pres- dards concerning the use of chemical sub- ence in the environment. stances and compounds in agriculture. It acts as a reference point for public health interventions in the case of major health emer- Congresses, training and publications gencies, accidents, and natural calamities. The Institute promotes national and interna- Advice tional scientific congresses relating to its field of activity. It organizes training, specialization and The Institute provides advice to the Italian Gov- refresher courses on public health and health ernment and Regions with regard to their services for the staff of the Italian National health plan and the environment for public Health Service and other institutions dealing health care. It gives public health advice in col- with public health care (Table 2.1). The research laboration with ISPESL (National Institute for results carried out at ISS are published in Prevention and Safety at Work) and other insti- national and international literature and in pub- tutions dealing with the production and use of lications by the Institute itself. Annexes - 307

Fig. 2.1: Structure of the National Institute of Health.

Office of the Director General

Technical Secretariat for General Affairs Secretariat for Relations with Press Offices Technical Secretariat for the Official Pharmacopoeia

DIRETOR’S OFFICES

DIRECTOR GENERAL

Administrative Service Applied Toxicology

Personnel Service Biomedical Engineering

Cell Biology

Clinical Biochemistry

Comparative Toxicology GENERAL SERVICE Library and Ecotoxicology

Environmental Hygiene LABORATORIES

Epidemiology and Biostatistics

Food

Haematology and Oncology

Biotechnology Immunology

Building and Equipment Bacteriology and Medical Mycolo- Maintenance Office gy

Data Management Metabolism and Pathological Bio- chemistry

Documentation Organ and System Pathophysiolo- gy

Editorial Activities Parasitology

Quality and Safety of Animal Experimentation Pharmaceutical Chemistry

Safety Pharmacology

Secretariat for Cultural Affaires Physics

Ultrastructures

Veterinary Medicine

Virology 308 - Annexes

Table 2.1: Training and didactic activities carried out by the Istituto Superiore di Sanità (National Institute of Health) – 1998-1999. Laboratory analysis and Laboratory Medical Diagnostics. • IX theoretical–pratical course on laboratory diagnosis of human parassitosis on gastro-intestinal and uro-genital tracts.

Training, documentation and communication. • “Medlars” archives available on Internet: Pubmed and Grateful Med. • Scientific communication and Mass Media. • Training course for managers of the Public Relations Offices. • Training activities and evaluation of the Health Unit. • Continuous training activities in health planning. • Communication in the scientific field. • Advanced instruments for information searching in the toxicological sector. • Methods and didactic techniques in the training activities. • Family Counselling. Environmental health. • Refresher course on the health effects of pollutants. Guidelines, environment control, regulation, public information. • VI course on veterinary medicine and environmental pollution. • Training course on dangerous substances and products. • Health and environment: priority, monitoring and interventions methods, evaluations and risks management. • Course on Cancerogenesis: action mechanisms and risk evaluation. Food and nutritional health. • Obesity and food disorders. • Health requirements on zoo-technical and food productions, from foodstuff control to the analysis of residuals on foods. Hygiene, epidemiology and public health. • Statistical methods in epidemiology – Basic course. • Basic epidemiology course. • Epidemiology and ischaemic cardiopathy prevention. • Advanced course in epidemiology. • Epidemiological methods for the evaluation of vaccines. • VII course – Package for the statistical analysis of data. Basic elements. • Organization and evaluation of bronco-pneumology services: the example of chronic obstructive bronco-pneumopathy. • Statistical methods in epidemiology – Advanced course. • Epidemiological surveillance in HIV infections and sexually transmitted diseases. • Theoretical-practical course: diagnosis, therapy and prophylaxis of malaria. • IV theoretical-practical course – insects and acari on health. • Emerging and re-emerging infections. Health research. • V course on clinical research methods. • V course – Experimental projects and variance analysis. Evaluation of services and health economy. • Productivity and costs of health services. • Construction techniques, administering and evaluation of a questionnaire. • Planning and evaluation of the interventions on SERT – Part I: methods. • Management Control in Local Health Units. • Evaluation and planning of the interventions on SERT – Part II: contents. Annexes - 309

• Epidemiology for mental health services. • Training and refresher course for inspectors of the adoption principles good practice in laboratories. • Strategic planning and budgeting in Local Health Units. • III course on biological bases, evaluation of effectiveness, planning and organization of oncological screenings. • Quality controls on Radiotherapy. Professional accreditation and institutional quality based on the minimal requirements and voluntary professional accreditation. • Top management and technical-professional choices: introductory course on intervention effectiveness evaluation. • Accreditation and certification of cyto-histopathology laboratories.

1999 Epidemiology and research in the health services. • Introductory course of Pharmacoepidemiology. • Top management course. • Quality control on radiotherapy. • Statistical methods in epidemiology – Basic course. • Course in basic epidemiology. • Experimental designs and variance analysis. • Advanced epidemiology course. • Professional quality, institutional crediting based on the minimal requirements and professional voluntary development. • Design, conduction and analysis of a sample research project for the evaluation of courses to be provided • Epidemiological methods for vaccine evaluation. • Statistic methods on epidemiology – Advanced course. • VI course on the methodology of clinical research. • Introduction to the packages used for the statistical analysis of data. • Development and certification of cyto-histopatology laboratories. • Training and refresher course for inspectors for the adoption of principles of good laboratory practice.

Services, training, documentation, • Training course for managers of Public Relations Offices communication, health education. • Biomedical information freely distributed on Internet by the National Library of Medicine. • Scientific communication and Mass Media. • Communication in Health. Strategies and internal/external techniques. • Productivity and costs of health services. • Ethics, quality and development in the Public Relations office. • Evaluation and projects on continuous training activities in health. 310 - Annexes

ANNEX 3: Istituto Superiore per la Prevenzione e la Sicurezza del Lavoro (National Insti- tute for Prevention and Safety at Work)

The “Istituto Superiore per la Prevenzione e la sure to electromagnetic fields; in the study of Sicurezza del Lavoro” (ISPESL) reports to the safety mechanisms for plants and equipment, Minister of Health and is a technical-scientific and in the identification of new pathological body of the National Health Service. It acts as a aspects caused by noise and vibrations. national centre for information, documentation, research and experimentation for safe- ISPESL consultancy and technical assis- guarding health and safety at work. tance The Institute also has close working contacts with Europe given that its experts participate in Consultancy and technical assistance from a wide variety of European Commissions and it ISPESL can be obtained upon request concern- is the focal point in Italy for the European ing problems which despite being of general Agency for Safety and Health at Work, based in interest, are also specific to prevention and Bilbao, Spain. safety issues at work. The ISPESL is divided into six Central Depart- Public bodies and private companies look to ments: Industrial Hygiene; Occupational Medi- ISPESL’s competence and professionality for cine; Safety; Technologies; Production Plants consultancy on such complex and difficult to and Interaction with the Environment; Docu- define matters such as: mentation, Information and Training; Type- • the unification of industrial certification pro- approval and Certification. cedures on national and community levels; ISPESL is represented throughout Italy by 36 • intervention in problems concerning “market Local Departments, stretching from Aosta in monitoring” connected with EC MARKINGS for the North to Palermo in the South, all of which products, especially agricultural machinery; make ISPESL both ready and able to intervene • guidelines for the implementation of Legisla- in any part of Italy. tion Decree No. 626/94 and No. 494/96; • decompression chambers; ISPESL research activities • use of anti-neoplastic agents in hospitals and similar structures; ISPESL’s scientific research programmes are on • registers of exposure levels to carcinogens; three “Fundamental Areas”, namely techno- • registers of exposure levels to biological logical safety; definition, measurement and agents; assessment of risks; definition, measurement • development of an information system in the and evaluation of effects. Within these three field of Prevention (S.I.PRE.). areas, ISPESL’s research concentrates on subjects considered to be priority in terms of ISPESL Information and Documentation emerging problems, based on the frequency Service and seriousness of the accidents and occupational diseases recorded. This approach has Since its very inception, ISPESL has been produced important results: for example, in required to provide information on specific the definition of the limits for toxic substances technical and scientific data to people involved which pollute most common technological in the field of prevention. ISPESL has always cycles; in the relationship between industrial tried to tailor the editorial content of its publi- plants and the environment; in the evaluation cations to the different needs of its diverse of the health risk possibly associated to expo- readers (public and private sectors, safety spe- Annexes - 311

cialists, designers, builders, consultants, trade- role following the cultural change outlined in unionists, etc.). One of the main objectives of the Community Directives incorporated into the Institute has been the development of a Italian Legislation beginning with the enforce- useful information system designed to help ment of Legislative Decree No. 626/94. safety officers in small and medium-sized com- The Institute has developed guidelines in the panies in particular, as well as those involved in area of professional training, dedicated to the public sector in the area of risk assessment. adult education; these consist of constructive This system is already operational through training and information schemes as well as ISPESL’s Internet web sites. high quality training kits designed for the main Providing information is an important and on- players in prevention programmes for compa- going commitment for ISPESL. This is per- nies. formed by means of the publication of numer- ISPESL is also planning to produce distance ous technical papers and magazines. training courses in the near future, using Documentation produced by ISPESL can be the Internet or videoconferencing technolo- obtained by filling in a request form or by gies. enquiring at the appropriate desk in any ISPESL office. The internal documentary sources are ISPESL regulatory proposals contained in a library housing 24 000 volumes, including the original research study reports The constant and assiduous presence of ISPESL’s from working groups; monographs on specific experts in Committees, Commissions and risks; data banks containing information on Working Groups makes an effective and impor- accidents at work; the most important data tant contribution towards normative activities bases on OSH available on CD-ROM, and cours- within the context of international, national es such as on-line connections with the most and regional bodies. up-to-date scientific services. Juridical databas- The constant contact maintained with grass es giving normative and legal information on root levels, in addition to the work of individual accident prevention, industrial and environ- experts, technical committees and working mental hygiene are also available, as are Italian groups, makes this contribution even more and European official Journals and the micro- authoritative. fiche collection of ILO-CIS documents. Examples of normative proposals which ISPESL has drawn up include: ISPESL training and education • technical specifications for application in the production of pressure vessels; The training and education departments of • analysis and evaluation of decompression ISPESL have recently taken on a more important chambers. 312 - Annexes

ANNEX 4: Agenzia per i Servizi Sanitari Regionali (National Agency for Regional Health Care Services)

The National Agency for Regional Health Care c) organization of a national programme for Services was instituted in 1993 within the context guidelines development and implementation: of the general reorganization of the Italian Min- d) identification of “essential levels of care”, istry of Health and endowed with operational that is services which have to be assured to Ital- and specialized functions focusing on innovation ian citizens in the light of the nature of the tar- and development in the health care sector. geted needs and of their effectiveness and The most distinctive aspects of the Agency con- appropriateness of use. cern its institutional activity, which is placed at Some additional tasks have been attributed to the interface between the Ministry of Health the Agency by Law No. 419 of 1998 and Leg- and regional authorities. In general terms, the islative Decree No. 229 of 1999 (see Annex 9 primary objective of the institutional activity is and Chapter XV, respectivley). The connections to support both these institutions in assuring between the Agency and the Ministry of Health the quality of the services provided, increasing and Regions are assured by: the ability of the entire health care system to • the presence on the Board of Administra- provide effective interventions through efficient tion and the Auditors’ Committee of mem- organization in the delivery of care. bers appointed by both governments and In particular, legislative acts identify specific regions; tasks of the Agency, according to the targets of • the reports on the activities of the Agency the Italian National Health Service contained in that the director submits to the Minister of the National Health Plan 1998-2000. These Health as well as to the Permanent State- tasks include: Regions Conference (a Body specifically a) monitoring the performance of regional appointed to confront issues and take deci- health services to assess the extent to which sions on general topics of common inter- equity, efficiency and effectiveness are achieved est, particularly in the case of health care in health care delivery; where the 21 Regions and Autonomous b) development of accreditation criteria for Provinces of Italy must organize their own health services: services). Annexes - 313

ANNEX 5: Training activities carried out by some IRCCS as of 1996

Istituto Dermopatico dell’Immacolata (I.D.I.) Training courses in ethics and management for doctors and managers as well as managers of health care structures; courses on health management; continuing education in psychosomatic dermatology, dermato-cosmetology and dermato- pathology; two-year training courses on clinical interview and psychodiagnostic techniques; supervision activities of operations on clinical psychology and psychotherapy of adults; international school of research and training on clinical psychology and psychotherapy; professional school of nursery; courses on surgery assistance; fellowships on epithelium biology, physiopathology; permanent training: clinical conferences, monthly congresses on clinical cases; weekly meetings on dermopathology; Journal Club; weekly meetings; clinical-biological updating seminars; courses on clinical epidemiology for dermatologists and courses on biostatistics for clinical research and epidemiology studies.

Istituto S. Maria e S. Gallicano The Institute promotes conferences, seminars and refresher courses for doctors and health operators in the dermatological field; teaching courses of dermatological interest of the Medical Hospital School in Rome are organized within the Institute on a regular basis.

Istituto Nazionale di Riposo e The Institute collaborates with its structures and operators in specialization cours- Cura per Anziani INRCA es in several disciplines at the Universities of Ancona, Roma, Firenze, Milano, Cosenza, Urbino and Camerino; the Institute manages one school for rehabilitation therapists and two schools of podology it operators and organizes refresher courses in ageing-related diseases for doctors and professional nurses. The Insti- tute also collaborates with the main voluntary associations in organizing training courses on voluntary aid for old people.

Ospedale Generale Regionale The Institute is a head office for professional nurses, obstetricians and medical “Casa Sollievo della Sofferenza” radiology technicians and has agreements with 38 specialization schools at six Ital- ian University seats. It hosts yearly training courses in medical genetics, emathol- ogy, radiology, diabetes, cutaneous istopathology and bioethics.

Fondazione Stella Maris (STELMAR) The Institute hosts many academical courses of the Universities of Pisa, namely: official courses in child psychiatry and pedagogy, post-degree specialization courses in psychology and child psychiatry within other specialization schools and university diplomas for therapists on neuro-psychomotricity for children age.

Istituto Nazionale Neurologico “Carlo Besta” The Institute contributes to training of medical and paramedical staff collaborating with many specialization schools of the university and makes its structures available to recent graduates for practical apprenticeship activities. Furthermore, it organizes theoretical-practical refresher courses for doctors and health operators active in the field of neuro-sciences, as well as weekly seminars for the continuing clinical-scientific education of the staff. 314 - Annexes

ANNEX 5: Training activities carried out by some IRCCS as of 1996. (continued)

Istituto Neurologico Mediterraneo “Neuromed” Since 1994, the NEUROMED institute has been one of the didactic mainstays of the University of Rome “La Sapienza” and hosts university diploma courses for rehabilitation therapists; the NEUROMED Institute is also home to several post- university specialization schools.

Ospedale Oncologico The Institute organizes periodic seminars on clinical oncology, as well as specific courses, and national and international congresses; doctors teach in the specialization school of oncology at the University of Bari. The CARSO Consortium (Train- ing centre basic scientific research in the oncological field) was founded in 1995 and its purpose is to train young graduates in oncological scientific research. The Institute is a part in the TUCEP association (Tiber Umbria Comett Education Pro- gramme) aimed at improving the training of university and industry staff by disseminating information concerning advanced technologies (courses, staff and didactic material exchange, etc.).

Istituto Nazionale per la Ricerca sul Cancro The Institute hosts the Genova specialization school of oncology and the specialization school of plastic surgery, as well as specially designed school for technicians and biotechnologies; there are also university courses for students in clinical and experimental oncology. Seminars, training courses, meetings and congresses are held periodically.

Istituto Europeo di Oncologia A specific sector of the Scientific Committee is committed to organize and coordinate all training activities in oncology, both internally and externally; particular attention is given to the Continuing Medical Education Programme organized for all the clinical-scientific staff of the Institute, including once weekly meetings for a collegial debate on the most important clinical cases and clinical studies in progress or to be started and twice weekly meetings dedicated to the diagnostic evaluation of controversial cases and on emerging issues of experimental research. The “external” training activities have enabled GPs to continuously keep abreast of developments in the oncology field. GPs are fundamental interlocutors of the Institute, organising didactic meetings on principal tumour pathologies in order to attract maximum participation; a series of programmes which includes a direct involvement by GPs on topics of mutual interest have been launched, i.e. treatment protocols, methods to give up smoking, studies on the effects of Chernobyl radiation on the young carried out by the European Oncology Institute. The Insti- tute hosts the advanced courses of the European Oncology School and some activities of the Italian Institute for the Study of Breast Pathologies of the Euro- pean Society of Mastopathy.

Istituto Nazionale per lo Studio The Institute carries out yearly advanced improvement courses on clinical oncolo- e la Cura dei Tumori gy, courses of radiology, cytopathology and radiotherapy for technicians and nurses. Every two years there are refresher courses on tumour pathologies; courses are provided by the Institutes of immunology, biometrics and medical statistics and radiology of the University of Milano; there is also a school for professional nurses. Annexes - 315

Istituto Nazionale per lo Studio Conferences, seminars, national and international congresses for protocols of clin- e la Cura dei Tumori “Senatore Pascale” ical and experimental research, such as: the National Cancer Institute – Bethes- da (USA); Frederick Cancer Research – Frederick (USA); M.D. Anderson Cancer Center – Houston (USA); UK Coordinating Committee on Cancer Research (UKCCCR) – London (UK); Uganda Virus Research Institute – Entebbe (Uganda); Fred Hutchinson Cancer Research Center – Seattle (USA); IFREMER – Toulose (France).

Istituto Regina Elena per lo Studio The Institute provides biannual scholarships and hosts annual refresher and spe- e la Cura dei Tumori cialization courses (Data Club, Journal Clubs, conferences of Italian and foreign researchers). Every two years, the Institute organizes a congress on “Diagnostic and Oncological Radiobiology” and a course for the Hospital Medical School; the Institute has a school of nursing and in conjunction with the Univiersities “La Sapienza”, “Tor Vergata” and “Sacro Cuore” contributes to the didactics of degree courses, short degrees and specialization courses.

Istituto Ortopedico Rizzoli Teaching courses for students of orthopaedic clinical medicine on locomotion system pathology and road traumatology, are offered. The Institute provides hospi- tality to the specialization schools of the University of Bologna on: orthopaedics, physiokinesitherapy for rehabilitation technicians, anatomical-surgical training and school of nursing. The Institute carries out annual advanced specialization courses on orthopaedical and traumatism issues: courses on musculo-skeletal pathology, specialization courses on biomaterials in prosthetic surgery, specialization courses on podology, specialization courses on biomedical technologies and joint surgery, theoretical/practical courses on arthroscopical surgery. Workshops on knee prosthesis.

Centro Cardiologico “Fondazione Monzino” Pre-degree university teaching; integrated courses on cardiology for fourth year medical students , including: cardiology, cardiosurgery, circulation physiopathology, cardiovascular semiotics, angiology, cardiosurgery semiotics. These courses are taught by graduate technicians and researchers employed by the University of Milano. Post-degree specialization schools: cardiology, surgery, cardiosurgery, thoracic surgery, internal medicine, sports medicine, rheumatology, clinical pharmacology; fellowships on cardiovascular surgical physiopathology; specific didactic activities: cardiological intensive therapy, post-surgery intensive therapy, cardio- electrophysiology, pace-maker fitting, clinical haemodynamics, experimental haemodynamics, extra-body ultrasonography, intraesophageal ultrasonography, intravascular ultrasonography, rehabilitative medicine; schools for professional training; schools for extra-body circulation during cardiosurgery operations.

Ospedale Pediatrico Bambino Gesù The hospital has special agreements with many university clinics for the following specialization schools: paediatrics, paediatric surgery, orthopaedics and traumatology, cardiology, plastic and reconstruction surgery, nephrology (I), health and preventive medicine, clinical psychology (II), special schools for therapists of rehabilitation for children. The hospital hosts a school for infancy surveillance and also organizes refresher and theoretical/practical courses for doctors and health operators. 316 - Annexes

ANNEX 5: Training activities carried out by some IRCCS as of 1996. (continued)

Istituto “Eugenio Medea” The Institute includes the following didactic resources: therapists from rehabilitation schools, teachers, and awards university diplomas on social services; furthermore, it organizes permanent clinical seminars annual specialization and refresher courses for health operators and. It offers help to recent graduates from Italy and abroad, and arranges apprenticeships for students in many medical and paramedical specialization schools.

Fondazione Pro Juventute “Don Carlo Gnocchi” Given the special agreements with several Universities, the Institute makes its structures available to students and graduates for the finalization of degree the- ses, specialization diplomas and research fellowships. In particular, the Institute hosts university diploma courses on biomedical engineering for rehabilitative orientation and specialization schools in neurology. It also hosts professional training and refresher courses for health and care operators, in collaboration with public bodies, as well as local beginners courses to train the disabled how to use PCs.

Centro Residenziale Clinica S. Lucia This centre offers a wide variety of courses including: specialization school in urol- ogy, diseases of the respiratory system, practical post-graduate apprenticeships for psychologists, university diplomas for rehabilitation therapists, schools for speech therapists. Many Italian schools and several Italian Regional institutions recommend their students do apprenticeships in this structure.

Ospedale Maggiore di Milano It hosts the principal specialization schools on medicine and surgery. The Institute, in the context of the compulsory professional updating, carries out yearly courses for the health and non-medical sector and for the technical administrative and economic sector. The Institute organizes monthly clinical-pathologic conferences and meetings relating to the activities of clinical-scientific areas of the Hospital. The Institute hosts a school for professional nurses as well as for technicians in medical radiology.

Policlinico S. Matteo The Institute hosts many didactic activities in medicine, surgery and courses for dental technicians of the University of Pavia. There are 50 specialization schools in medicine, as well as research fellowships and several university diploma courses. Specific grants ensure a professional and scientific training. The Hospital also carries out many theoretical-practical courses and internships for doctors and researchers from different Italian and foreign institutions. A diploma course in nursing and a university diploma in the laboratory and clinical-rehabilitative field are organized for technical staff.

Istituto Scientifico H San Raffaele There are courses on medicine, dental technicians and a university diploma in nursing; in addition, there are specialization schools on thoracic surgery, endocrinology, homeostatic diseases, ophthalmology, paediatrics, medical nephrology, tropical medicine, a school specifically dealing with neuro-phisiopathology techniques and six research fellowships. In collaboration with the Catholic University of Milano, it runs a biannual course on the development of human resources, including the first managerial course for health managers. In conjunction with the Polytechnic of Annexes - 317

Milano, a university diploma course in biomedical engineering has been set up; a school of medicine and human sciences was founded in 1981, offering courses in: philosophy, medicine theology, anthropology, history of medicine, history of civili- sation and bioethics. A fellowship on molecular and cellular biology was established in 1993 in the DIBIT as a section of the London Open University. There is also an experimental institute dealing with biology, health and research. In four units, the Department of Cognitive Sciences has recently organized courses in the following subject matters: linguistics; action, perception and cognition; rationality and decision; and cognitive neuropsychology. The research centre on business, professions and political activity ethic is fully operational.

Fondazione Centro Auxologico Italiano In collaboration with the Italian Auxological Centre (Milano presidium) and the University of Milano, the Institute carries out didactic activity for the specialization schools of: cardiology, endocrine sciences, health and preventive medicine.

Fondazione Salvatore Maugeri According to a special agreement, the Foundation works with the following spe- Clinica del Lavoro e della Riabilitazione cialization schools of the University of Pavia (occupational medicine, allergology cardiology, pneumology, physic medicine and rehabilitation), University of Bari (work medicine, cardiology), University of Napoli (geriatrics, neurophysiology, plastic surgery) University of Padova (psychology), University of Torino (psychology, physical medicine and rehabilitation, department of electronics-bioengeenering), University of Genova (respiratory system, physical medicine and rehabilitation). The Institute of Pavia hosts an integrated course on occupational medicine and the school addresses special issues on techniques for environmental and work health. 318 - Annexes

ANNEX 6: Training activities carried out by some Regions and Autonomous Provinces*.

Autonomous Province of Bolzano

1997-1999. Training activities for non-medical Health Personnel carried out by the Scuola Superiore di Sanità. The 1997-1998 global budget totalled ITL 5 556 million, whilst for 1999 the budget is estimated at ITL 4 787 million.

1997-1999. Training activities for non-medical Health Personnel carried out by Local Health Agencies. The budget allocated for the three-year period is approximately ITL 3 135 million.

1997-1998. Specialist Training for Doctors in Italian and Foreign Medical Schools The Province of Bolzano has allocated approximately ITL 2 767 million.

1998. Post-Degree Training for Non-medical Health Personnel in Italy and Abroad. The amount allocated to this activity in 1998 was approximately ITL 187 million.

1998. Training for General Practitioners. The total amount is approximately ITL 651 million.

Autonomous Province of Trento

1998-1999. Training for Health Personnel carried out by the Autonomous Province of Trento. The total amount is approximately ITL 1 519 million.

1998-1999. Training for Health Personnel performed by the Local Health Agencies. The amount is approximately ITL 500 million.

Abruzzo Region

1998. Training for Health Personnel. In 1998 the Abruzzo Region spent a total of ITL 5 billion on training courses for the personnel of infectious diseases department, General Practitioners and Health Care Technicians.

Basilicata Region

1998. Training for Health Personnel. The total amount allocated for training 3 351 health operators was approximately ITL 2 200 million.

* Based on an on-going survey carried out by the Ministry of Health of Italy Annexes - 319

Sicilia Region

1998. Training for Health Personnel. The budget for 1998 for training activities carried out by the Sicilian Local Health Unit Agencies and Universities is estimated at approximately ITL 1 483 million.

Campania Region

Training for Health Personnel. The Regional Authority of Campania provides training activities for health personnel in the following areas: • University diplomas on health; • Medical school specializations; • Professional courses for opticians and dental technicians; • Education courses for health care technicians. Resources devoted: unknown.

Valle d’Aosta Region

1997-1998 During the period 1997-1998, the Region of Valle d’Aosta provided funds for training professional nurses, health care technicians, Managers, speech pathologists, midwives, rehabilitation therapists and physiotherapists. The total amount allocated for such training activities totalled approximately ITL 227 million.

Veneto Region

1999. Training for Health Personnel. Total budget amount for non-medical Health Personnel is ITL 1 316 million while ITL 489 million is for Medical Personnel. 320 - Annexes

ANNEX 7: Research activities of the IRCCS as of 1996.

NAME RESEARCH FIELD

Istituto Dermopatico dell’Immacolata (I.D.I.) Basic clinical research; genic dermatosis; paediatric dermatology; cellular and molecular biology; molecular biochemistry; study on immune-mediate and allergic diseases; immunology; dermatological oncology; pharmacological research; degenerative; research on oxidative stress; cutaneous ulcerative diseases; tissue engineering; cutaneous ulcers o vascular ; molecular epidemiology; cellular ageing; pathologies of vascular diseases.

Istituto S. Maria e S. Gallicano Skin cancer; allergic and professional dermatoses; microbiology; physiopathology; applied informatics; photobiology; epidemiology of dermatomycosis.

Ente Ospedaliero Specializzato in Neoplastic and pre-neoplastic lesions; dyspepsia; chronic liver diseases; chronic Gastroenterologia “Saverio de Bellis” intestinal inflammatory diseases; antenatal care and diseases of the reproduction.

Istituto Nazionale di Riposo e Prevention and treatments of geriatric disability; tumours; ageing of the nervous, Cura per Anziani - INRCA neuroendrocrine and immunological systems; arteriosclerosis and cardiovascular complications.

Ospedale Generale Regionale Paediatric diseases: Duchenne’s muscular dystrophy; genetic deafness and malfor- “Casa Sollievo della Sofferenza” mations; congenital haemocromatosis; cystinuria; myiotonic dystrophy; risk factors for stroke; cancer; genic mutilations; genic therapy; transplantation.

Fondazione Stella Maris (STELMAR) Neurologic pathologies in newborns; phisiopathology of speech; neurophi- siopathology; malformation syndromes; motor, language and cognitive rehabilitation; psychotherapy.

Istituto Nazionale Neurologico “Carlo Besta” Molecular and cellular biology; genetics; immunology; neuroanatomy and elec- trophisiology; nervous-system and metabolic diseases, neuromuscular and degenerative diseases.

Istituto per le Malattie Infettive Study on HIV and AIDS and other infectious diseases; basic epidemiological “Lazzaro Spallanzani” research; epidemiology; prevention strategies for hospital infections transmitted through blood; epidemiology and prevention of HIV-related Tuberculosis; HIV epidemiology on pregnant women; research on viruses and viral diseases: CMV, HIV, HCMV, HPV, HCV and HHV; T-lymphocyte response assessment in the natural hys- tory of HIV infection.

Fondazione Neuro-degenerative diseases: dementia, Parkinson’s syndrome; neuro-immuno- “Istituto Neurologico Casimiro Mondino” logical diseases; neuro-psychopathology; neurology; and neuro-epidemiology.

Istituto Neurologico Mediterraneo “Neuromed” Molecular pathology; neurology; cardiology; angiology; neuro-epidemiology; neurological re-abilitation; diagnostic imaging; neuro-surgery. Annexes - 321

Associazione Oasi Maria SS. Autism and Nuclear Magnetic Resonance: research and rehabilitation therapy; dementia: biohumoral, neuro-physiological, neuro-psychological and psychological studies; Down’s syndrome; fragile chromosome X syndrome; Angelman’s syndrome; Prader-Willi’s syndrome.

Centro di Riferimento Oncologico Istituto Genetic alteration studies; neoplastic transformation and progression; lynpho-pro- Nazionale Tumori Centroeuropeo - Aviano liferative diseases;; human tumours studies; cellular and molecular biology; AIDS- related neoplasms; epidemiological research; breast cancer: chemio-prevention; relations between diet and cancer; carcinogenesis of gastric tumours; study, diagnosis and therapy of malignant lymphomas; breast and ovarian cancer; gastroen- teric tumours.

Ospedale Oncologico Oncology: breast cancer; study on lymphoma, ovarian, bladder and lung neoplasms; serums and cytoplasmatic proteases; gynaecological neoplasms: ovary carcinoma; studies on cellular kinetics, colon-rectal, testicle and stomach neoplasms, soft-tissues sarcomas, multiple myeloma, kidney carcinoma.

Istituto Nazionale per la Ricerca sul Cancro Oncology: Carcinogenesis mechanisms, molecular oncogenesis and cellular cycle; Genova genic control and cellular division; neoplastic growth: factors and hormones; angiogenesis, HLA system; the origin of lynphoma; human retro-virus studies.

Istituto Europeo di Oncologia - Milano Diagnosis and treatment of tumours; Oncology; chemio-prevention and cellular cycles, molecular carcinogenesis; epidemology; bio-statistics; nuclear medicine; cellular and molecular biology; studies on carcinogenesis; mechanisms of breast and prostate cancer; clinical research on tumours, especially colon-rectus, stomach, breast, lung and ovary.

Istituto Nazionale per lo Studio e Cellular and molecular biology; cellular genetics and cytogenetics; Oncology: la Cura dei Tumori - Milano chemiotherapy and radiotherapy; immunology and immunotherapy; particular emphasis is given to telemedicine application programmes.

Istituto Nazionale per lo Studio AIDS retro-virus research; studies on DNA and RNA; oncology: angiogenesis and e la Cura dei Tumori “Giovanni Pascale” neoplastic proliferation; molecular genetics; clinical research on human tumours, expecially: breast, head-neck, colon-rectus, lung cancers as well as melanomas.

Istituto Regina Elena per lo Studio e Oncology: neoplastic progression; immunology; studies about DNA; research on la Cura dei Tumori papilloma virus; neoplasms; clinical research.

Istituti Ortopedici Rizzoli Epidemiology; bio-compatibility of implant materials; physiological and pathological bio-mechanics; immunology; cytology; endo-prosthesis; reconstructive surgery; orthopaedical surgery; traumatology; conservative surgery.

Centro Cardiologico “Fondazione Monzino” Cardiology; anaesthesia and cerebral protection during extra-body circulation; cardiovascular surgery and physio-pathology; research on myocardial thrombosis; studies on cerebral protection in heart surgery; congestive heart failure, ischaemic heart disease, hypertension and heart electro-physiology; aortic pathology; ischaemic cardiopathy. 322 - Annexes

ANNEX 7: Research activities of the IRCCS as of 1996. (continued)

Istituto “Giannina Gaslini” - Genova Molecular genetics; oncology; diseases of muscles; metabolic diseases; molecular biology; nephrology, child neuro-psychiatry; gastroenterology; endocrinology; pneumology; neuro-degenerative diseases; immunopathology; cardiology; obstetrics; Down’s syndrome diagnosis; paediatrics; infectious diseases; correction of malformations; microsurgery; neuro-surgery, vascular surgery.

Ospedale Pediatrico Bambino Gesù - Roma Prenatal and paediatric surgery; paediatric transplants; studies on lung-hypopla- sia; paediatric oncology; paediatric malformation research; care of severe chronic diseases in children and rehabilitation; research on AIDS retro-virus; clinical and molecular genetics.

Istituto per l’Infanzia Burlo Garofolo - Trieste Reproduction physiopathology: sterility, abortions, sexually transmitted diseases; gynaecology; paediatric endocrinology; research on female’s genital tumours; rehabilitation; neuro-psychiatry; physiopathology; ovary oncology; vertebral diseases; paediatric surgery; health education.

Istituto Scientifico “Eugenio Medea” Rehabilitation technologies; electro–physiology; psychiatry; neuromuscular diseases; biology.

Fondazione Pro Juventute “Don Carlo Gnocchi” Bio-medical technologies; neurology; orthopaedics; sports medicine; ergonomics; rehabilitation and treatment of paraplegic subjects; diseases of the nervous-system; biology; pathogenesis.

Centro Residenziale Clinica S. Lucia - Roma Neurology; neuropsychiatry; neuropathology; neuro-physiopathology; biome- chanical research; electro-iso-kinetics.

Ospedale Maggiore di Milano Biotechnology; biomedical technologies; cardiovascular; transplants; gastroenterology; hypertension; cardiology; immunology; respiratory failures; biology.

Policlinico S. Matteo - Pavia Transplantation surgery; virology; bio-technologies and biomedical technologies; clinical and experimental immunology.

Istituto Scientifico H San Raffaele - Milano Diabetes and metabolic-endocrine diseases; laboratory and biomedical technologies; bio-technologies; studies on HIV retro-virus.

Istituto Auxologico Italiano Physiopathology; rehabilitation of disabilities; studies on Prader-Willi’s syndrome and Angelman’s syndrome; cerebro-vascular diseases; endocrinology; cardiology; metabolic diseases; neurology; biotechnology; biomedical technologies; molecular biology; epidemiology; bioethics.

Fondazione Salvatore Maugeri Health at work: prevention of occupationalrisks; rehabilitation medicine and pre- Clinica del Lavoro e della Riabilitazione vention of handicaps; neuro-motor and cardio-respiratory disabling diseases; pathology; study on functional deficits and rehabilitation; applied clinical research; environmental research and biology; occupational medicine and safety at work; studies on heart failure; research on bio-energetic human activity. Annexes - 323

ANNEX 8: Declaration of the Third Ministerial Conference on Environment and Health (signed in London on 18 June 1999).

PREAMBLE environment and health impacts of increasing traffic, especially due to road transport. 1. We, ministers and representatives of Euro- • Within countries, the lack of economic pean Member States of WHO1 responsible for growth and stability are urgent problems for health and the environment gathered in Lon- some countries, denying a sustainable basis for don from 16 to 18 June 1999. Our meeting protecting the environment and health. Special built on foundations laid at the previous Envi- assistance is needed for countries in transition ronment and Health conferences in Frankfurt and some Member States which face more (1989) and Helsinki (1994) and marked a new severe and often worsening environment and commitment to action in partnership for health problems. We express our horror at the improving the environment and health in the continuation of armed conflicts in some coun- twenty-first century. tries of the Region, and the resulting loss of life and destruction of natural environments, health care establishments and recreational EUROPE’S ENVIRONMENT AND HEALTH AT THE TURN zones; there is a need for international assess- OF THE TWENTY-FIRST CENTURY ment of the damage being done to the environment and health, and for immediate reme- 2. We welcome the WHO report An overview dial action2. of environment and health in Europe in the • Some trends are of great concern, such as cli- 1990s. It demonstrates that the ten years since mate change and ozone depletion; unsustain- our first conference have seen various achieve- able patterns of consumption and production; ments, which give grounds for optimism about and the tendency to conceive of development improvements in Europe’s environment and and economic growth as unrelated issues, health in the twenty-first century. However, it unaware of the fact that economic develop- also shows that the Region still faces many ment is fundamentally linked to improvements urgent environment and health challenges. in people’s health. 3. Many problems remain unsolved and new 4. However, there are many reasons for being challenges have emerged. confident that improvements can be made. • In the Region as a whole, serious problems • In the Region as a whole, democracy has con- remain and some are increasing. We draw par- tinued to be strengthened, and cooperation ticular attention to the increasing inequity between countries has increased notably. In between and within countries and the need for addition to the Environment and Health process, international cooperation on transboundary many other processes such as Environment for problems, such as air pollution; to the continu- Europe, programmes of the European Commis- ing lack of reliable access to sufficient safe water sion (EC) and the process of enlargement of the and sanitation for many communities, as a basic European Union (EU) have also particularly con- prerequisite for health; and to transport, where tributed to this; coordination with them can yield solutions have yet to be found to the adverse added value for the environment and health.

1 A supportive statement of the European Commission is contained in Annex 8.1. 2 The Russian Federation feels that it is necessary to carry forward more concrete action aimed at eliminating as soon as possible the environment and health consequences of military conflicts and at precluding such conflicts in the future. 324 - Annexes

WHO’s Health for All policy framework for the health and safety. We invite countries to intro- European Region for the twenty-first century duce and/or carry out strategic assessments of (Health21) provides an additional, positive the environment and health impacts of proposed framework for making further progress, and its policies, plans, programmes and general rules. European Centre for Environment and Health We invite international financial institutions also (ECEH) can serve as a platform of scientific and to apply these procedures. There will be appro- operational support for effective action. priate participation of nongovernmental organi- • Within countries, most have exploited the zations (NGOs) and members of the public in the foundations laid by international cooperation, procedures set out in this paragraph. by developing health strategies that embody the principles of Health for All, National Envi- Water and health ronmental Health Action Plans (NEHAPs), National Environmental Action Programmes 8. We adopt the Protocol3 on Water and Health (NEAPs) and Agenda 21 strategies. to the 1992 Convention on the Protection and • There are many positive trends, such as Use of Transboundary Watercourses and Inter- increases in life expectancy at birth in many national Lakes, (MP.WAT/AC.1/1999/1 – EHCO countries; advances in technology and in its use 020102 P, Conference document EUR/ICP/ for the benefit of human health; improved edu- EHCO 020205/8 05299 – 24 March 1999), with cation; progress in research and understanding; the aim of preventing, controlling and reduc- greater involvement of civil society in environ- ing the incidence of water-related disease ment and health matters; and the continuing through collaboration on water management willingness of governments to take strong mea- and protection of health and the environment. sures to protect health and the environment. We thank the Government of Hungary for 5. In the past ten years we have learnt that by leading the process of developing this Protocol working in intersectoral partnerships and increas- and call upon all Member States of the United ing coordination of relevant initiatives, we can Nations Economic Commission for Europe have a greater effect in reducing the negative (UN/ECE) and those in the European Region of impacts of human activity on the environment WHO to ratify both the Protocol and, if they and health. We are determined to strengthen have not already done so, the parent Conven- and expand our coordination and partnership, as tion. We also thank the Secretary-General of we work towards improved environment and the United Nations for acting as the Protocol’s health within sustainable development. Depositary. 9. Within the framework of the Protocol we will take all appropriate measures for the purpose COMMITMENT TO ACTION of achieving: a) adequate supplies of wholesome drinking- 6. We wish to record here, in the paragraphs water which is free from any micro-organisms, below, the actions that we have agreed at our parasites and substances which, owing to their third Conference. numbers or concentration, constitute a potential danger to human health. This shall include Cross-cutting action the protection of water resources which are used as sources of drinking water, treatment of 7. We will carry out environmental impact water and the establishment, improvement and assessments fully covering impacts on human maintenance of collective systems;

3 Austria and Turkey have a general reservation with regard to the Protocol and its title. Austria believes the title should read “Protocol on Water and Health for the European Region”. Annexes - 325

b) adequate sanitation of a standard which suf- national capacity in the area of water and water ficiently protects human health and the envi- management. We offer to share our experience ronment. This shall be done especially through with other Regions of the world and commend the establishment, improvement and mainte- the Protocol to other regional commissions of the nance of collective systems; United Nations and regional offices of WHO. c) effective protection of water resources used as sources of drinking water, and their related Transport, environment and health4 water ecosystems, from pollution from other causes, including agriculture, industry and 12. We recognize that transport plays a major other discharges and emissions of hazardous part in life today, contributing to quality of life, substances. This shall aim at the effective access to goods and services, and economic reduction and elimination of discharges and and social development. We are, however, con- emissions of substances judged to be haz- cerned that the current patterns of transport in ardous to human health and water ecosystems; the European Region, dominated by road d) adequate safeguards for human health motor vehicles, are not sustainable and have against water-related disease arising from the significant adverse impacts on health and the use of water for recreational purposes or for environment, and that the potential health the production of fish from aquaculture, from benefits of sustainable transport have not been the water in which shellfish are produced or adequately explored. from which they are harvested, from the use of 13. Although positive steps have been taken waste water for irrigation or from the use of internationally and within our countries, pre- sewage sludge in agriculture or aquaculture; sent transport strategies still result in high dam- e) effective systems for monitoring situations like- age costs, of which only a small part is borne by ly to result in outbreaks or incidents of water- the transport sector. related disease and for responding to such out- 14. We are determined at international and breaks and incidents and the risk of them. national levels to effectively reduce the significant 10. We will apply the Protocol’s provisions to adverse effects and barriers to community devel- the maximum extent possible pending its entry opment created by transport-related air, soil and into force. We ask UN/ECE and WHO to assist water pollution, accidents and noise, greenhouse in that, especially by: gases emissions and damaging of forests and to a) organizing meetings of the Signatories, open increase the health benefits of physically active to all States who are entitled to sign the Proto- transport modes, notably cycling and walking col, to the European Commission and to all rel- (including to and from means of public trans- evant international intergovernmental and non- port). Actions taken in the relevant fora to governmental organizations; achieve these different aims should be consistent, b) providing the necessary infrastructure within notably concerning the reduction of greenhouse the framework of existing budgets. gases and other health-damaging emissions. 11. We call for close cooperation in this work 15. By adopting the Charter on Transport, Envi- between UN/ECE, WHO, the United Nations Envi- ronment and Health, we confirm our commit- ronment Programme (UNEP), the United Nations ment to make transport sustainable to health Development Programme (UNDP) and EC, as well and the environment. We thank the Govern- as other relevant international organizations. We ment of Austria for leading its development, specifically call upon UN/ECE and UNDP to make jointly with WHO. a useful contribution to national strategies for 16. We undertake to adopt the principles and sustainable development by helping to build up strategies set out therein and commend them

4 Turkey has a reservation on paragraphs 14–18 of the Declaration. 326 - Annexes

as a basis for progress at international, nation- the follow-up of other international transport al, subnational and local levels. We will and environment decisions and in particular with strengthen the enforcement of current legisla- the follow-up of the UN/ECE Vienna Declaration tion and strive to implement the measures in on Transport and the Environment. the Charter’s plan of action, especially those 18. We call on WHO and other international aimed at attaining the health targets, and to organizations to continue to support these integrate health and environment concerns into efforts by fulfilling the roles identified for them current and new transport, water and land use in the Charter. We recognize that further planning policy, inter alia by: efforts will be needed in the future, beyond a) pursuing cooperation and promoting implementation of the Charter, in order to approaches whereby health and environment achieve transport that is sustainable for the requirements are taken into account and environment and health. We invite WHO and authorities in both sectors are involved in deci- UN/ECE, jointly and in cooperation with other sion-making processes related to transport, international organizations, to provide an water and land use planning and infrastructure; overview of relevant existing agreements and b) promoting modes of transport, such as pub- legal instruments, with a view to improving and lic transport, walking and cycling, and water, harmonizing their implementation and further land use planning and technologies that have developing them as needed. A report on this the best public health impact; overview should be submitted at the latest by c) assessing the environmental health impacts spring 2000, recommending which further and costs of transport, land use and infrastruc- steps are needed. That report should cover the ture policies and investments; possibility of new non-legally binding actions d) promoting policies designed to internalize and the feasibility, necessity and content of a transport-related environmental health costs; new legally binding instrument (e.g. a conven- e) developing policies to protect populations at tion on transport, environment and health, extra risk of health effects from transport; focusing on bringing added value to, and f) investigating further the health risks from avoiding overlaps with, existing agreements). transport that are not yet fully clarified; 19. A decision on negotiation of such an instru- g) monitoring the links between transport and ment shall be taken as soon as possible after health and the progress made towards the tar- the submission of the report, at a meeting of gets identified in the plan of action; ministers of transport, environment and health h) promoting pilot projects and research proof Member States or their representatives, con- grammes focused on achieving transport that is vened for that purpose by WHO and UN/ECE at sustainable for health and the environment; the latest by the end of the year 2000. i) raising public awareness and individual responsibility and ensuring access to information about Implementing NEHAPs in partnership the impacts of transport on environmental health, and increasing public participation in decision- 20. We commit ourselves to NEHAP implemen- making on transport projects and strategies; tation, by taking the measures which we have j) cooperating with and giving all possible sup- identified as necessary in our countries and by port to countries with severe transport-related taking the lead in mobilizing all other actors. health problems in promoting transport sus- 21. We welcome the proposals, recommenda- tainable for health and the environment. tions and requests for national and internation- 17. We commit ourselves to making appropriate al action in the document Implementing arrangements for the follow-up and monitoring NEHAPs in partnership. We thank the govern- of implementation of the Charter, by integrating, ments of Bulgaria and the United Kingdom for where necessary, with existing mechanisms for leading the development of those proposals, Annexes - 327

jointly with WHO and the NEHAP Task Force. In environment and health projects. We recom- particular, we endorse and strongly support: mend that a strong commitment should be a) the integration of environment and health made, involving multi-partner approaches, to concerns, on a reciprocal basis, into national implementing local environment and health policies and plans, plans for economic sectors, activities identified as a result of both national legislation and finance; and local planning processes. b) the implementation and further develop- 24. We recommend that local plans to improve ment of NEHAPs through action at sub-nation- health and the environment should be drawn up al and local levels, in coordination with other and implemented in our countries, either as part local plans, and with support for environment of other relevant plans, such as Local Agenda 21 and health professionals with relevant training or Healthy Cities Action Plans, or separately. and resources and capacity-building in environ- These should be developed preferably by existing ment and health management; bodies and designed to achieve distinct local c) the development of national communication environment and health improvements. and public information strategies, as a two-way 25. We will identify mechanisms within each of process, in matters affecting the environment our countries, involving but not limited to pub- and health; lic sector organizations, community groups and d) efforts to involve the public and NGOs at the NGOs, to promote well managed local environ- earliest possible stage in the implementation ment and health projects, develop data and and further development of NEHAPs and relat- monitoring systems, and devise a training and ed initiatives under Agenda 21; and information exchange programme on alterna- e) continuation of assistance by Member States, tive intersectoral approaches for local imple- international organizations, subregional groups mentation. These mechanisms should also pro- and institutions for strengthening environmen- mote health issues within the context of tal health services and enforcement agencies, Health21 and Agenda 21. for capacity-building measures in environmen- 26. We recommend that the European Environ- tal health and for the provision of specific assis- ment and Health Committee (EEHC) should tance with their accession-related needs to promote steps by WHO and other relevant countries of central and eastern Europe which organizations, to: are candidates for membership of the EU. a) provide policy advice and guidance on local 22. We resolve, acting in partnership with inter- environment and health implementation initia- national organizations and institutions as tives; appropriate, to fulfil the roles and undertake b) assess the need for, and prepare as needed, the tasks identified for achieving effective further informative and practical publications implementation of NEHAPs throughout the for implementers of local environment and Region. Further, in the spirit of the Ministerial health projects on: Declaration adopted at the Fourth “Environ- • strengthening community involvement in ment for Europe” Conference (Århus, 23–25 local implementation; June 1998), we resolve to coordinate the • the roles of private sector and financing insti- implementation of our NEHAPs with NEAPs and tutions in local implementation; other environmental policies or plans. • data collection and local needs assessment.

Local processes for environment and Environment and health research for health action Europe

23. We welcome the book produced by WHO 27. We welcome the proposals made in the entitled Source book on implementing local document Environment and health research for 328 - Annexes

Europe, prepared by the European Science to high-quality environment and health infor- Foundation (ESF) in liaison with EC and WHO. mation. We note that electronic information We will use it as one of the bases for a pan- technologies are dramatically increasing the European, integrated and coordinated effort possibilities for such access and we recognize for research in the priority areas identified in that many key institutions, organizations and this Declaration. agencies, including the Food and Agriculture 28. We recognize our need for research of the Organization of the United Nations (FAO), the highest reliability and quality as a tool for deci- Organization for Economic Co-operation and sion-making, and we will encourage and sup- Development (OECD), UN/ECE, UNEP, UNDP, port EC, ESF and WHO and, where relevant, the European Community (through EC and the other international organizations in developing European Environment Agency (EEA)), and their collaboration to this end. Such collabora- WHO in cooperation with NGOs are already tion would facilitate pan-European consultation making efforts towards this end. To further this and coordinated action on environment and objective, we request EEHC, with the involve- health research. We will encourage our appro- ment of NGO representatives from both the priate national bodies to implement the environmental and health sides, to take steps to research proposed in the above-mentioned promote the development of a comprehensive, document. easily accessible network of databases on envi- 29. We recognize that policies and individuals’ ronment and health issues, involving as appro- behaviour do not take sufficiently into account priate representatives of major providers and the link between the environment and health. users of environment and health information. We call upon researchers to investigate this gap Furthermore, we encourage governments and and to develop methods aimed at overcoming it. international organizations to incorporate this objective in their information policies. Access to information, public participation 33. We invite WHO to establish a working and access to justice in environment and group, involving representatives of the media, health matters environmental health professionals, NGOs and other key partners in assessment or communi- 30. We affirm our commitment to giving the cation of risks, to elaborate guidelines on risk public effective access to information, improv- communication, having regard to relevant ing communication with the public, securing international work in this field and taking into the role of the public in decision-making and account the need to rigorously apply the pre- providing access to justice for the public in envi- cautionary principle in assessing risks and to ronment and health matters. We warmly wel- adopt a more preventive, pro-active approach come the document Access to information, to hazards, and to report to the next Environ- public participation and access to justice in ment and Health conference. environment and health matters and recom- 34. We resolve to promote the application of mend it for consideration, inter alia by the Sig- the principles of the Århus Convention in inter- natories to the Århus Convention, in further national decision-making processes dealing deliberations in this field. with the environment and health5. We recom- 31. We request WHO to explore options for mend the provision of opportunities for effec- strengthening public rights to information, par- tive participation by NGOs in the preparation by ticipation and justice in the sphere of health. intergovernmental organizations of instru- 32. We recognize the desirability of the public ments having significant environmental or having streamlined, low-cost and timely access human health implications.

5 Turkey has a reservation on this sentence. Annexes - 329

Health, environment and safety manage- to the community by the activities of enterpris- ment es. We will create or strengthen information systems on health, environment and safety 35. We note with appreciation the document management and performance in enterprises, Towards good practice in health, environment making them accessible to employers and and safety management in industrial and other employees as well as to national and foreign enterprises and we recognize our role and the investors. role of stakeholders in implementing its objec- 38. We invite all concerned intergovernmental tives. We thank the Government of Poland for bodies and international organizations to pro- leading its development and will take into mote a holistic concept of health, environment account its holistic and participatory approach and safety management in enterprises, both as a basis for assessing, strengthening or estab- nationally and internationally, by applying a lishing, as appropriate, national policies precautionary, step-by-step approach. designed to facilitate good practice in all types of enterprises. Early human health effects of climate 36. We recognize the importance of instituting change and stratospheric ozone depletion workplace measures to meet public health needs and goals, and the right of workers to be 39. We recognize that human-induced changes involved in the decision-making process on in the global climate system and in stratospher- those measures. We will promote good practice ic ozone pose a range of severe health risks and in health, environment and safety management potentially threaten economic development in enterprises, in collaboration with stakehold- and social and political stability. National action ers in our countries such as local authorities, is urgently required by all countries to reduce enforcement agencies, business (including and prevent as far as possible these environ- small and medium-sized enterprises), trade mental changes and to limit the exposure of unions, NGOs, social and private insurance human populations in Europe to climate institutions, educational and research institu- change and increased ultraviolet irradiation, tions, auditing bodies, and providers of preven- and the consequential health risks over the tion services. The current regulatory frame- coming decades. works and economical appraisal related to 40. We welcome and support the conclusions health and safety should be, if necessary, and recommendations of the document Early strengthened for this purpose and self-regula- human health effects of climate change and tory mechanisms (voluntary initiatives and stratospheric ozone depletion in Europe and agreements) should be used as complementary recommend the establishment of a Europe- measures. We invite WHO and the Internation- wide interagency network for monitoring, al Labour Organization to work together to researching and reviewing the early human assist countries in developing processes, involv- health effects of climate change and of stratos- ing all stakeholders, for implementation of pheric ozone depletion, developing and advo- environmental practice which also promotes cating prevention, mitigation and adaptation public health, and to develop close cooperation policies, and identifying specific research priori- with the European Commission to assist the ties in that field. We invite ECEH to act as a co- candidate countries for membership of the ordinator in this network as part of the global European Union to meet their obligations. programmes under the Inter-Agency Commit- 37. We recognize the rights and needs of work- tee on the Climate Agenda endorsed in 1998 ers to be informed of occupational and envi- by the World Health Assembly and to link it to ronmental health hazards in the workplace, and other relevant global programmes such as of the public to be informed of hazards posed those arising from the United Nations Frame- 330 - Annexes

work Convention on Climate Change and the affirm the potential of economic instruments as Montreal Protocol on Substances that Deplete policy tools that contribute effectively to the Ozone Layer. improving health and the environment, and we 41. We will support the identification, develop- recognize that it is possible to make far more ment, standardization, evaluation and broad use of them. use of systems for monitoring and assessing 45. We will develop, so far as is needed, our changes in environmental indicators, bio-indi- capacities to carry out economic analysis, in cators of health risk and impacts on health as order to place this tool at the service of efforts well as indicators of population health status to meet our commitments, and in particular to across Europe. These systems must be coordi- strengthen our national systems of strategic nated with global monitoring activities. environmental impact assessment so as to 42. We will develop our capacities, as necessary, include health concerns, and to ensure the inte- to undertake national health impact assessments gration of environment and health considera- with the aim of identifying the vulnerability of tions into policies (paragraph 21(a)). We will populations and subgroups and will ensure the promote the full internalization of environment necessary transfer of know-how among coun- and health costs, and the preparation of strate- tries. We will make these assessments available gies for achieving this. for possible consideration in the forthcoming 46. We welcome the principles for action set Third Assessment Report of the Intergovernmen- out at the end of the document Economic per- tal Panel on Climate Change. spectives on environment and health and we 43. We will carry out ongoing reviews of the invite the relevant organizations including social, economic and technical prevention, mit- OECD, UNDP, UNEP, UN/ECE, WHO and the igation and adaptation options available to World Bank: reduce the adverse impacts of climate change a) to consider these principles for strengthening and stratospheric ozone depletion on human their cooperation on environment and health health. We will support the implementation of economics; prevention, mitigation and adaptation strate- b) to further integrate environment and health gies taking into account national impact assess- concerns as they relate to economics into their ments, e.g. by strengthening surveillance activ- activities and development operations. ities, with appropriate public education and 47. We invite EEHC to assist in the coordination with special reference to vulnerable groups. of these efforts and we commit ourselves to participating actively in them and to ensuring Economic perspectives on environment that the relevant actors provide the support and and health commitment required.

44. We recognize that policy in many sectors Children’s health and the environment affects environmental health, and that economic analysis can express costs in explicit terms 48. We recognize the special vulnerability of and hence encourage decision-makers to take children and reproductive health to environ- them into account. We further recognize that mental threats. We are determined to develop economic analysis helps with setting priorities policies and implement actions to provide chil- with regard to risk reduction, by assessing the dren with a safe environment, including during cost-effectiveness of such measures. However, prenatal and postnatal development, towards we recall that there will remain uncertainties the highest attainable level of health. We will about the extent of some risks as well as in eco- take effective measures to make rapid progress nomic evaluations; we therefore reaffirm our towards WHO targets for improving child commitment to the precautionary principle. We health and arresting the worrying trends of cer- Annexes - 331

tain childhood diseases in some areas of the the Region on the basis of key indicators of the Region. To this end, we support the 1997 Dec- state of children’s health and the relevant envi- laration of the Environmental Leaders of the ronmental conditions. Eight on Children’s Environmental Health as a 51. In doing this we request EEHC to take fully framework for developing policies and actions into account the work already carried out by for our countries. other international and regional bodies such as 49. We recognize that both the social and the UNEP, the United Nations Children’s Fund physical environments influence health, behav- (UNICEF), the European Community (through EC iour and the social and personal development and the EEA), WHO and other international orga- of children. We advocate the development of nizations and NGOs. We express our willingness prevention-oriented policies and actions, to cooperate in the exchange of information and including education, as the most effective experiences through a coordinating mechanism, means of protecting children from environmen- and to help one another in developing policies tal threats to health. and implementing public health interventions. 50. We will develop initiatives in our countries to give greater emphasis in all relevant programmes to the need to prevent the exposure THE FUTURE OF THE ENVIRONMENT AND HEALTH of children to environmental threats. To this PROCESS end, we endorse the priority areas identified in the document Children’s Health and the Envi- The role of the European Environment and ronment and will develop policies and imple- Health Committee ment actions and public health interventions in these areas. We request EEHC to identify meth- 52. We appreciate the usefulness of the Euro- ods and mechanisms to: pean Environment and Health Committee a) promote the exchange of information and (EEHC) in achieving the goals set out in para- experience across the Region on the manage- graph 23 of the Helsinki Declaration on Action ment of preventive strategies on, and research for Environment and Health in Europe and into, asthma and allergies; acknowledge its achievements. We have there- b) support and enable the exchange of infor- fore decided that EEHC should continue as an mation and experience in implementing public advisory body for a further five years from 1 July health interventions on childhood accidents 1999. We still consider the terms of reference and injuries; of EEHC as given in paragraph 27 of the Helsin- c) develop and implement public health inter- ki Declaration to be appropriate, with the addi- ventions to prevent smoking and the effects of tion of the following three functions which will environmental tobacco smoke, in particular by be necessary to follow up on the decisions we encouraging Member States to participate in have made here in London: the global and regional Tobacco-Free Initiative; • to monitor, facilitate and promote the imple- d) promote and encourage public health mea- mentation of actions decided by environment sures in areas of emerging concern about envi- and health ministers at the London Conference; ronmental impacts on children’s health, on the • to promote cooperation and coordination basis of the precautionary principle; with associated organizations and related e) establish how the particular needs of children processes, and in particular the linkage can be highlighted and prioritized within the between the Environment for Europe process NEHAP process and other relevant national pro- and the Environment and Health process; grammes; • to develop further the Environment and f) develop an effective mechanism for monitor- Health process in Europe by facilitating and pro- ing and reporting progress annually throughout moting partnerships and intersectorality at all 332 - Annexes

levels in the field of environment and health a source of technical expertise for the Region that lead towards sustainability. and of scientific support for the identification of 53. We wish to encourage greater transparen- effective evidence-based environment and cy in the work of EEHC. We agree to extend the health policies. We are extremely grateful for membership of EEHC by adding six representa- the support given to WHO-ECEH, principally by tives of major groups, including NGOs, local Italy, the Netherlands and France. Partnership government, business, trade unions, environ- with WHO-ECEH should include: ment and health professionals nominated by a) ensuring that WHO-ECEH continues to play their appropriate organizations. We take note an effective role and further develops its capac- of its method of working and secretariat ities, especially for implementation of the arrangements as set out in EEHC’s report to our actions we have agreed at this conference; conference. b) encouraging more Member States and WHO to share in providing the necessary financial Commitment to partnership support to WHO-ECEH. 57. We want to enhance solidarity and, in par- 54. We reaffirm the commitments to partner- ticular, to recognize and effectively address the ship made at our previous conferences. We differences in environment and health status request EEHC to take forward the further devel- between countries of the Region. Partnership opment of partnership in the Environment and with Member States should include: Health process as set out below. a) assisting countries of central and eastern 55. We will continue to collaborate with all Europe (CCEE) and newly independent states EEHC member organizations and other Euro- (NIS), particularly through building up their pean and global organizations and processes. capacities and providing support to the reform Partnership with the international community of regulatory structures, including the develop- should include: ment and implementation of environment and a) increasing cooperation and coordination health “acquis communautaire” as part of the between relevant international activities, process of accession to the EU for a number of including by encouraging interagency accords CCEE, so as to maximize benefit to the envi- so as to streamline efforts and increase effec- ronment and health; tiveness, and ensuring close coordination of the b) a “bottom-up” approach, in which countries Environment and Health and Environment for identify priorities for international activity and Europe processes; are committed to implementing them; b) promoting effective coordination with inter- c) promoting sub-regional collaboration, for national economic and trade organizations, in example to build on the successful model offered order to minimize environmental concerns in by the Visegrad, Nordic/Baltic, Central Asian and the era of globalization; Sofia groups, and other collaboration between c) exchanging information with environment countries such as that between Azerbaijan, Arme- and health processes in other Regions; nia and Georgia in the south Caucasus Region, in d) reaching out to the scientific community, developing and implementing NEHAPs; particularly through its research organizations, d) sharing information and promoting increases recognizing that we live in a rapidly changing in the understanding of scientific, technical and world and therefore need to improve our fore- economic matters, as a basis for innovative and sight of environment and health matters and effective policies; anticipate future developments, as well as deal- e) carrying forward a strong programme of ing with problems already identified. implementing NEHAPs in partnership, as envis- 56. WHO-ECEH was established after our first aged in this Declaration and coordinated by conference (Frankfurt, 1989) and has served as EEHC. Annexes - 333

58. We welcome the extensive activity taking 61. We pledge ourselves to work in partnership place at local level to protect the environment to implement the actions we have set out in and health, through the Healthy Cities net- this Declaration. We stress the importance of work, Local Agenda 21 and many other net- monitoring the results and invite EEHC to pre- works and initiatives. We want to pay more sent an updated overview of the environment attention to enhancing local-level activity and and health in Europe at our fourth conference. making full use of the skills and experience We recognize that much remains to be done to available. Partnership with local agencies address the challenges that environmental should include: degradation poses to the health of the people a) promoting the recognition and representa- of the European Region. We believe that we tion of local authorities, health agencies and must continue our joint efforts in order to build other local agencies in the Environment and on the progress we have so far made towards Health process and in other relevant interna- this goal. tional activities; 62. We reaffirm our support for the global and b) supporting local initiatives aimed at meeting regional conventions and commitments, and NEHAP and Agenda 21 objectives. express our willingness to consider the develop- 59. We appreciate the value of the contributions ment of further appropriate international made by NGOs and members of the public to instruments that can make it easier to carry out, environment and health matters, and we specifi- in cooperation with relevant international orga- cally welcome NGOs’ contributions to prepara- nizations, the actions we have decided here. tions for this conference and their participation in it. Partnership with NGOs should include: The way forward a) promoting NGO participation in the future development of the Environment and Health 63. We will work with all relevant international process and maximizing the contribution that organizations in taking forward the actions NGOs and members of the public can make to agreed in this Declaration and maintaining actions that it initiates; momentum in the Environment and Health b) promoting public participation, access to process. We pledge our political support for this information and access to justice as a cross-cut- and will give technical and financial assistance ting priority in line with the Århus Convention;6 within our available means. We consider that c) ensuring that NGOs can participate in the coordination with the Environment for Europe implementation of the commitments to action ministerial conferences should be as close as agreed at this Conference and in regular and possible and welcome the decision to hold the transparent reviews of progress. next of those in Ukraine in 2002. We also wel- 60. We recognize that economic activity can come and express our willingness to contribute make a significant difference to the environ- to the “Rio plus ten Conference” to take place ment and health, as well as to social and eco- in 2002. nomic development. Partnership with business, 64. Representatives of NGOs and other major industry, trade unions and private and public groups across the Region have participated in our sector enterprises should include: meeting and its preparatory processes and have a) making greater use of the existing knowl- made a valuable contribution. We welcome the edge and capacities that the economic sectors work of the Healthy Planet Forum that has been often have to support our efforts; held in parallel with this meeting, and the b) promoting the economic sectors’ participa- increasingly close working relationship develop- tion in the Environment and Health process. ing between Member States, NGOs and major

6 Turkey has a reservation on this sub-paragraph. 334 - Annexes

groups that this represents. We wish this working • our achievements and areas needing greater relationship to continue and to strengthen. We efforts; note with interest the conclusions of the Healthy • its activities, workplan and budget require- Planet Forum and request the European Environ- ments. ment and Health Committee to consider all of 66. Furthermore, we invite EEHC to present them carefully and to make recommendations on detailed proposals to all Member States in an appropriate response in its next annual report. 2002, through the European Regional Commit- 65. We ask EEHC to report annually to the tee of WHO and the Committee on Environ- Regional Committee for Europe of WHO and to mental Policy of UN/ECE, on agenda items for a the Committee on Environmental Policy of fourth Environment and Health Conference in UN/ECE on: 2004, to be hosted by Hungary. Annexes - 335

ANNEX 8.1: Statement of the European Commission.

The European Commission welcomes the documents to all the conference topics such as pub- ments that have been presented and adopted lic participation, climate change, economic per- at the third Ministerial Conference on Environ- spectives, implementation of national environment and Health. mental health action plans (NEHAPs) and research. The new protocol to the 1992 Convention on the Protection and Use of Transboundary The Commission firmly supports the objectives Watercourses and International Lakes, that has put forward in these documents but is not in a been prepared jointly by the Parties to the Con- position to adopt or sign at this time the Con- vention with the UN/ECE and WHO, contains ference documents. However, it wishes to stress significant provisions to reduce water-related that the possibility of signing at a later stage disease. will be given consideration. In the meantime, the Commission will continue to work actively The objectives of the Charter on Transport, with international organizations, in particular Environment and Health are to ensure better WHO, in contributing to the promotion of coordination between health, environment and these objectives and the attainment of a higher transport sectors, and to establish health as a level of health and a safer environment. The priority consideration in transport policy. Commission intends to take into account, in its future activities and within its competence, the The Ministerial Declaration sets out an initiatives that have been launched in the docu- approach for the future and records commitments. 336 - Annexes

ANNEX 9: Law No. 419 of 30 November 1998a) - “Delega” to the Government for the streamlining of the National Health Service and the adoption of a Consolidation Act in the matter of the organization and functioning of the National Health Service. Amendments of Legislative Decree No. 502 of 30 December 1992.

With the approval of the Chamber of Deputies Conference referred to in Article 8 of Law and the Senate of the Republic; Decree No. 281 of 28 August 1997. The opinion of the Unified Conference shall immediate- THE PRESIDENT OF THE REPUBLIC OF ITALY ly be transmitted to the aforesaid Parliamentary Committees. On the parts of the drafts of the PROMULGATES legislative decrees referred to in paragraph 1 hereof that have repercussions on the organi- the following law: zation of labour and employment relationships, as also on the pensionable age, the most repre- ARTICLE 1 sentative trade unions were heard. (Delegation to the Government) 4. The exercise of the delegation conferred by means of the present law shall not, taken as a 1. The Government is hereby delegated to issue whole, imply additional burdens for the State within one hundred and eighty days of the date budget and the agencies referred to in Articles of the coming into force of the present law one 25 and 27 of Law No. 468 of 5 August 1978 or more Legislative Decreesb) to amend and and subsequent amendments thereof. integrate Legislative Decree No. 502 of 30 December 1992 and subsequent amendments thereof on the basis of the guiding principles ARTICLE 2 and criteria set out in Article 2 hereunder. (Guiding principles and criteria 2. The delegation referred to in the first para- of the delegation) graph hereof shall be exercised in respect of the competencies transferred to the Regions by 1. In issuing the legislative decrees referred to in means of Legislative Decree No. 112 of 31 Article 1, the Government shall abide by the March 1998 in implementation of title I of Law following guiding principles and criteria: No. 59 of 15 March 1997. a) pursue the full realization of the right to 3. On the drafts of the legislative decrees health and the principles and objectives provid- referred to in paragraph 1 hereof, each one of ed for by Articles 1 and 2 of Law No. 833 of 23 which shall be accompanied by a technical December 1978 and subsequent amendments report on the financial effects of the provisions thereof; contained therein, the Government shall obtain b) complete the regionalization process and the opinion of the Parliamentary Committees verify and complete the reorganization on competent in the subject matter and the finan- administration business lines of the structures cial consequence thereof, as also of the Unified of the National Health Service;

a) The “Legge Delega” refers to an act conferring allegated legislative power to the government. b) A legislative decree is a decree (administrative Act) through which a delegation provided by an act conferring delegated legislative power to the government, together with specific criteria, is implemented. According to current regulations, the draft legislative decree is submitted to the non-binding scrutiny of competent parliamentary committees and, finally, adopted by the Council of Ministers. It should not be confused with a decree by law, which is an emergency legislation, that can be adopted for 60 days by the Council of Ministers. If not endorsed by the Parliament or reiterated by the Council of Ministers, the decree by law approved by the Council of Min- isters loses its efficacy within 60 days. Annexes - 337

c) regulate the collaboration between the pub- 1997, the tasks and the technical-scientific and lic providers concerned, taking due account of coordination functions to the National Institute the equivalent structures according to the proof Health, the Agency for Regional Health Ser- visions of Article 4, para.1, of Legislative Decree vices and the National Institute for Prevention No. 502 of 30 December 1992 and subsequent and Safety at Work; amendments thereof, whose regulations have l) strengthen the role of the municipalities in been approved by the Ministry of Health; regu- the health and socio-sanitary planning proce- late and distribute the tasks between the pub- dures at the regional and local level, in addition lic providers and the private providers con- to setting up an appropriate Body at the region- cerned, especially those of a private and social al level, as well as in the procedures of assess- character not pursuing a profit, with a view to ing the results of the Local Health Unit Agencies attaining the health objectives defined by and the Hospital Agencies; make provision for health planning; the municipalities to have faculty of assuring, in d) guarantee the freedom of choice and ensure keeping with regional health planning and by that the exercise of this choice by the assisted allocating their own resources, assistance levels parties vis-à-vis the accredited structures and in excess of those guaranteed by the said plan- professionals with whom the National Health ning, even though the said municipalities Service maintains appropriate relations shall excluded from direct functions in and responsi- take place within the frame of health planning; bilities for managing the National Health Ser- e) ensure the participation of the citizens and vice; the health operators in the planning and the m) make provision for the Regions to have fac- assessment of the health services, give full ulty of creating Bodies for coordinating the implementation to the service charter also by health structures operating in the metropolitan means of verifications of the health services and areas referred to in Article 17, para.1, of Law also the widest possible dissemination of the No. 142 of 8 June 1990; qualitative and economic data inherent in the n) lay down time schedules, modalities and services provided; areas of activity for arriving at an effective inte- f) streamline the structures and the activities gration at the district level of the health services connected with the performance of health ser- with the social services, disciplining also the vices with a view to eliminating waste and mal- participation of the municipalities in the costs functioning; connected with the social benefits; establish g) pursue efficacy and efficiency in the health principles and criteria for adoption, at the pro- services to guarantee the citizens the principle posal of the Minister of Health and the Minister of distributive equity; of Social Solidarity, of an act of orientation and h) define guidelines with a view to identifying coordination as provided for by Article 8 of Law the control and verification modalities to be No. 59 of 15 March 1997 in substitution of the implemented in accordance with the institu- Decree of the Prime Minister No. 19 of 8 tional subsidiarity principle and on the basis of August 1985 published in the Official Gazette suitable indicators of appropriateness of the No. 191 of 14 August 1985 to ensure uniform prescriptions and the prevention, diagnosis, levels of socio-sanitary services with a degree of cure and rehabilitation services with a view to health integration, also in the implementation streamlining the utilization of the resources in of the National Health Plan; pursuit of the purposes set out in a) herein- o) in disciplining the management of the sani- above; tary role of structures of the National Health i) attribute, within the frame of the reorganiza- Service operating in the area of socio-sanitary tion of the Ministry of Health undertaken with- benefits of high integration, take due account in the meaning of Law No. 59 of 15 March of the interdisciplinary character of the said 338 - Annexes

structures and make provision for suitable period of time to assign tasks of a managerial access requirements in keeping with the nature relating to job categories other than remaining professional figures in the depart- doctors to persons with no pension scheme ment. The professional figures other than of who are in possession of a university degree management level operating in the area of and other specific qualifications; socio-sanitary services of high integration are to s) make provision for the Local Health Unit be identified by means of a regulation of the Agencies and the Hospital Agencies to have Minister of Health in agreement with the Min- faculty, exclusively for special applied projects ister of the Universities and Scientific and Tech- that do not substitute ordinary activities, of nological Research and the Minister of Social entering into training and employment con- Solidarity; the relative didactic orders are to be tracts for a limited period of time with persons defined by the universities as provided for by in possession of a university degree or with Article 17, para. 95, of Law No. 177 of 15 May non-graduate personnel in possession of specif- 1997 on the basis of general criteria deter- ic qualifications; mined by means of a decree of the Minister of t) within the frame of the assistance and pen- the Universities and Scientific and Technological sion scheme provided for by the legislation in Research to be issued in agreement with the force, render homogeneous the national insur- other interested Ministers, taking due account ance and pension contributions of subjects of the need for interdisciplinary training imple- appointed to the posts of general manager, mented by means of the collaboration of sever- administrative manager and health manager al university faculties and in keeping with the and making provision also for the application to competencies outlined in the professional pro- private employees of Article 3, para.8, of Leg- files; islative Decree No. 502 of 30 December 1992 p) in implementing Legislative Decrees No. 29 and subsequent amendments thereof; of 3 February 1993 and No. 80 of 31 March u) redefine the requirements for the post of 1998, make provision for the extension of pri- managing director of the Local Health Unit vate employment contracts to the health man- Agencies and the Hospital Agencies, making agers, determining also general criteria on the provision for the certification of attendance of basis of which work organization is to be disci- a regional training course in matters of public plined when national employment agreements health and health organization and manage- are negotiated, with special reference to the ment of a duration not exceeding six months in departmental model; accordance with modalities to be laid down by q) with respect to sectors, functions and objec- the Minister of Health, subject to a prior under- tives outline the modalities to discipline an standing being reached within the Permanent exclusive employment relationship is resulting Conference on the Relationships between the from a personal choice on the part of full-time Central Government and the Government of permanent managers of health care structures the 21 Regions and the Self-governed as of 31 December 1998. This is also to be Provinces, and simplify the modalities of hiring incentivated by means of the additional finan- and firing, bringing them into line with the cial benefits referred to in Article 1, para.12, of process of reorganization along business lines Law No. 662 of 23 December 1996, in accor- and the private and fiduciary nature of the rela- dance with application modalities to be defined tionship and the principle of management on the occasion of negotiating national responsibility; ensure the involvement of the employment agreements; municipalities and their representative Bodies in r) make provision for the Local Health Unit the procedure of revoking and the procedure of Agencies and the Hospital Agencies to have assessing managing directors in relation to the faculty of entering into contracts for a limited results achieved by the Local Health Unit Agen- Annexes - 339

cies and the Hospital Agencies as compared be defined on the basis of appropriate guide- with the objectives of regional and local health lines to be drawn up by the Minister of Health planning; lay down criteria for the revision of in agreement with the Minister of the Universi- the regulations governing the contract condi- ties and Scientific and Technological Research tions of the general manager, administrative after having heard the above-mentioned Per- manager and the health manager of the Local manent Conference; making provision also for Health Unit Agencies and the Hospital Agencies the said protocols to identify the university adopted through the Decree of the Prime Min- structures for the carrying out of health care ister No. 502 of 19 July 1995, relating to the activities on the basis of the Decree of the Min- possible integration of the annual salary to the ister of Health and the Minister of the Universi- attainment of the health objectives defined by ties and Scientific and Technological Research regional health planning and establishing that of 31 July 1997 published in the Official the salaries of the health director and the Gazette No. 181 of 5 August 1997; administrative director be defined in an amount z) link the strategies and the instruments of not inferior to that provided for by the national health research with the aims of the National employment agreement for the top positions Health Plan, establishing – by agreement of, respectively, medical and administrative between the Ministers concerned – modalities management; of coordination with overall biomedical v) guarantee the rationality and economic research and instruments and modalities of soundness of the interventions in matters integration and coordination between public regarding the training and continuing educa- research and private research; tion of health personnel, making provision for aa) redefine the role of the National Health Plan the periodic drawing up by the Government, in which are identified the health objectives, after hearing the Federations of the Profession- the uniform and essential assistance levels and al Associations, of guidelines intended for the the efficacious and appropriate services to be competent administrations and for the determi- ensured to all citizens and paid for through the nation by the Minister of Health, after hearing National Health Fund; refer to appropriate sci- the Permanent Conference on the Relation- entific Bodies of the National Health Service the ships between the Central Government and the task of identifying the criteria for the qualitative Governments of the 21 Regions and the Self- and quantitative assessment of the health ser- governed Provinces, of the staffing require- vices, organizing the participation in these Bod- ments of the health structures; this for the sole ies of accredited scientific societies, making purposes of the planning by the Minister of the provision also for quality certification systems; Universities and Scientific and Technological bb) lay down the time frames and the general Research of admissions to the degree courses modalities for activating districts and attribut- for the health profession and the distribution ing to them the resources defined in relation to between the various schools for the specialist the health objectives of their populations and, training of doctors and veterinary surgeons, as within the context of the redefinition of the role well as for the other professions in health ser- of the general medical practitioner and paedia- vice management; make provision for the trician freely chosen by each individual; estab- memorandum of understanding between the lish also the general modalities for their inte- Regions and the universities and the National gration into the district organization, relating Health Service structures referred to in Article 6, the variable portion of the benefits paid to the paras. 1 and 2, of Legislative Decree No. 502 of said professionals to the district programmes 30 December 1992 and subsequent amend- and the objectives defined by them, though ments thereof, intended for implementation always correlated in respect of the planned within the frame of regional health planning, to expenditure levels referred to in Article 8, 340 - Annexes

para.1 of Legislative Decree No. 502 of 30 of the Local Health Unit Agencies in accordance December 1992 and subsequent amendments with the provisions of Article 13 of Law No. 833 thereof; of 23 December 1978 and Article 14 of Leg- cc) re-organize the integrative forms of health islative Decree No. 502 of 30 December 1992 assistance referred to in Article 9 of Legislative and subsequent amendments thereof; Decree No. 502 of 30 December 1992 and sub- gg) define an accreditation model correspond- sequent amendments thereof, specifying that ing to the orientations of the National Health they refer to additional services over and above Plan in applying the criteria set out in Article 2 the uniform and essential levels defined by the of the Presidential Decree of 14 January 1997 National Health Plan, though integrated with published in the ordinary supplement to Official the latter, making provision also for the faculty Gazette No. 42 of 20 February 1997, which the of the Regions, the Self-governed Provinces and Regions implement in full respect of their own the local authorities and their consortia to par- planning choices, also with a view to keeping ticipate in the management of said integrative and periodically updating the list of services forms of assistance; provided as well as the waiting list for them, dd) without prejudice to the structural, techno- thus allowing for readily available and transpar- logical and organizational requirements ent data. referred to in Article 8, para.4, of Legislative hh) for the purposes of the accreditation of Decree No. 502 of 30 December 1992 and sub- public and private health structures, define sequent amendments thereof, lay down the minimum structure, equipment and personnel modalities and the criteria for the granting of standards that will ensure all the necessary ser- the authorization to build health structures; vices deriving from the functions required after simplify the procedures for the refurbishment accreditation; and technological modernization of the public ii) specify the distinctive criteria and characteriz- health assets, as well as for the construction of ing elements for identifying the Local Health residences for the elderly and for persons who Unit Agencies and the Hospital Agencies, pay- are not self-sufficient, financed according to ing particular attention to their minimum orga- Article 20 of Law No. 67 of 11 March 1988; in nizational characteristics and the survey of the the event of inertia or unmotivated delay by the Hospital Agencies at the national and interre- Agencies and the Regions and the Self-gov- gional level; erned Provinces in undertaking and completing ll) define the system of remuneration of those the said interventions, make provision for persons providing services, classified according reducing the funds already allocated [to the to the previsions of Legislative Decree No. 502 offenders] and their allocation to others; of 30 December 1992 and subsequent amend- ee) guarantee the activity of assessing and pro- ments thereof, giving due consideration – in moting the quality of the assistance, laying the case of private structures – to the specific down appropriate modalities for the participa- nature of those that do not have profit-making tion of the operators in training processes; ends, in full respect of the criteria of efficacy enhance the competencies of the council of and efficiency; health professionals in relation to the functions mm) together with payment for services on a of planning and assessing the technical-health tariff basis, lay down expenditure levels and and health care activities of the Agencies; negotiation modalities for plans of activities ff) define the general criteria on the basis of that define volumes and typologies of the ser- which the Regions determine institutes for vices, all of which are within the frame of the strengthening the participation of the social expenditure levels defined in relation to the organizations existing in the territory and of the capital expenditure and bearing in mind the citizens in planning and assessing the activities complexity characteristics of the services pro- Annexes - 341

vided in the national territory; lay down the amendments thereof; within the frame of mod- funding modalities of the hospital sectors with- ifying the conventional relationships provided in the Local Health Unit Agencies; for by the said regulations, make provision for nn) outline the modalities and the guarantees streamlining the access requirements for the by means of which the Agency for Regional purposes of permanent inclusion and the ongo- Health Services identifies, in conjuction with the ing revision of the conventional relationships, Regions concerned, the interventions to be with the exclusion, however, of the guaranteed adopted for recuperating efficiency, economy continuous medical service; and functionality in managing the health ser- rr) outline the modalities by means of which the vices and providing the said Regions with the prevention department referred to in Article 7 technical support for the drawing up of opera- of Legislative Decree No. 502 of 30 December tional programmes, forwarding the assess- 1992 and subsequent amendments thereof, to ments connected therewith to the Ministry of which within the frame of health planning Health; there are to be assigned resources in keeping oo) outline the modalities and the guarantees with the objectives defined in the National by means of which the Ministry of Health, after Health Plan and on the basis of the epidemio- having assessed the local situations and on the logical characteristics of the resident popula- basis of the reports forwarded by the Agency tion, gives its support to the management, for Regional Health Services as provided for in making provision for forms of coordination paragraph nn) hereinabove, sustains the pro- between the prevention activities carried out by grams referred to in the said paragraph nn); the districts and the departments of the Local applies adequate penalties in accordance with Health Unit Agencies; define the modalities of automatic mechanisms for reducing the funds coordination between the prevention depart- allocated in case of inertia or delay on the part ments and the regional environmental protec- of the Regions in adopting and implementing tion agencies; outline modalities to ensure that these programs, after having heard the opinion the public veterinary services of the Local of the Agency; identifies, in keeping with the Health Unit Agencies will have technical-func- opinion of the Agency and after consultation of tional and organizational autonomy within the the above-mentioned Permanent Conference departmental structure. forms of Governmental interventions aimed at 2. In keeping with the self-financing system of making good the most serious cases of such the health sector and within the limits of their possible inertia by the administrations; respective statutes and the implementation reg- pp) establish modalities and terms of reducing ulations relating thereto, the Valle D’Aosta the pensionable age of the management per- Region, the Friuli Venezia Giulia Region and the sonnel of the medical sector employed by the Autonomous Provinces of Trento and Bolzano National Health Service and, regarding universi- are to bring their legislation into line with the ty personnel, the age of ceasing health care legislative decrees implementing the present activities in full respect of their particular juridi- law. cal status; outline the age limits for the cessa- tion of the conventional relationships referred to in Article 8 of Legislative Decree No. 502 of ARTICLE 3 30 December 1992 and subsequent amend- (Amendments of Legislative Decree No. 502 ments thereof; of 30 December 1992) qq) exclude the entering into of new conventions with the subjects referred to in Article 8, 1. In Article 3, para.6, of Legislative Decree No. paras. 1-bis and 8, of Legislative Decree No. 502 of 30 December 1992 and subsequent 502 of 30 December 1992 and subsequent amendments thereof, after the second sen- 342 - Annexes

tence, there shall be inserted the following in Law No. 833 of 23 December 1978 and sub- words: “The measures appointing the general sequent amendments thereof and Legislative managers of the Local Health Unit Agencies Decree No. 502 of 30 December 1992, making and the hospital Agencies shall be adopted appropriate integrative and corrective amend- exclusively with reference to the requirements ments, as well as those necessary for the purpos- referred to in Article 1 of Decree by Law No. es of the [desired] coordination. Nine months 512 of 27 August 1994, converted into Law after the issue of the legislative decree referred to No. 590 of 17 October 1994, without there in the present paragraph the Government shall being any need for making comparative assess- submit a report on its state of implementation to ments”. At the end of the said para.6 there the competent Parliamentary Committees. shall be added the following sentence: “The 2. The legislative decree referred to in para- Regions shall centrally determine the parame- graph 1 hereinabove is issued after having ters for assessing the activities of the general heard the opinion of the competent Parliamen- managers of the Agencies, having due regard tary Committees and the Unified Conference for the attainment of the objectives assigned referred to in Article 8 of Legislative Decree No. within the framework of regional planning and 281 of 28 August 1998. The opinions are to be with particular reference to the efficiency, effi- expressed, respectively, within forty days and cacy and functionality of the health services”. within thirty days of the submission of the draft 2. In Article 6, para.1, of Legislative Decree No. of the legislative decree. The opinion given by 502 of 30 December 1992 and subsequent the Unified Conference shall immediately be amendments thereof, after the first sentence, forwarded to the competent Parliamentary there shall be inserted the following words: Committees. Within the thirty days following “Within the frame of the memorandums of the expression of the opinions of the compe- understanding referred to in the present para- tent Parliamentary Committees, the Govern- graph, the universities shall agree with the ment shall resubmit the draft legislative decree Regions and the Autonomous Provinces of to the same Committees, together with its Trento and Bolzano every possible utilization of comments and possible amendments, for their private health care structures, always provided definitive opinions, which shall be given within that they are accredited and that no structures twenty days. are available in the reference hospital/health unit and, subordinately, in other public structures”. ARTICLE 5 (Reorganization of prison medical services)

ARTICLE 4 1. The Government is hereby delegated to issue (Consolidation Act) within six months of the date of the coming into force of the present law one or more leg- 1. Within eighteen months of the date of the islative decrees to reorganize prison medical coming into force of the present law, the Gov- services, observing the following guiding princi- ernment is hereby delegated to issue a decree ples and criteria: containing a consolidation act of the laws and a) outline specific modalities for guaranteeing other acts having the force of law concerning the the right to health of the persons detained or operation and the functioning of the National interned by means of gradual inclusion in the Health Service, coordinating the dispositions of National Health Service, following appropriate the law decrees referred to in Article 1 herein- experimentation of organizational models, pos- above with those in force regarding the same sibly differentiated in accordance with the matters and, more particularly, those provided for needs and the realities of the territory, of the Annexes - 343

personnel and the health structures of the utilization of the resources at present allocated to prison’s administration; the Ministry of Grace and Justice in accordance b) assure the safeguarding of the security with para.1, clause e) and without any addition- requirements institutionally passed on to the al burdens to be borne by the State Budget. prison’s administration; c) make provision for the organization of a specific activity with a view to guaranteeing a level ARTICLE 6 of adequate health assistance services in keep- (Redefinition of the relations between ing with the specific conditions of detention or universities and the National Health Service) internment and the exercise of the certification functions relevant for the purposes of justice; 1. The Government is hereby delegated to issue d) make provision for control over the function- within a year of the date of the coming into ing of the health assistance services for force of the present law one or more legislative detained or interned persons to be entrusted to decrees for the purpose of redefining the rela- the Regions and the Local Health Unit Agen- tions between the National Health Service and cies; universities, observing the following guiding e) make provision for the allocation to the principles and criteria: National Health Fund, by means of a decree of a) strengthen the processes of collaboration the Minister of Treasury, the Minister of the between universities and the National Health Budget and the Minister of Economic Planning, Service, also by means of the introduction, of the financial resources relating to the gradu- where appropriate, of new management and ally transferred functions which are currently functional models integrated between Region registered in the budget of the Ministry of Jus- and university, that make provision for the set- tice, defining also the criteria and the modali- ting up of Agencies possessing an autonomous ties of their administration. legal personality; 2. Within eighteen months of the expiry of the b) within the framework of national and term referred to in para.1 hereinabove and regional health planning, assure the carrying after having heard the opinion of the compe- out of health care activities that are functional tent Parliamentary Committees, the Govern- to the needs of teaching and research; ment shall issue, taking due account, where c) ensure consistency between the health care appropriate, of the outcome of the experimen- activities and the needs of training and tation, one or moreLegislative decrees contain- research, whenever appropriate, also by means ing integrative or corrective provisions relating of departmental organization and appropriate to the Legislative decrees referred to in para.1 provisions in personnel matters. hereinabove. The delegation referred to in para.1 herein- 3. The delegation referred to in the present arti- above shall be subject to the provisions of Arti- cle shall be exercised by means of the exclusive cle 1, paras. 3 and 4, of the present law. 344 - Annexes

ANNEX 10: Consiglio Superiore di Sanità (National Health Council).

The National Health Council is the most ancient planning and financing: - health structures and body of the Italian Public Health. It originated personnel and clinical matters (blood, trans- almost one century before the institution of the plants, etc.); public health and infectious dis- Ministry of Health as an advisory board on eases; food hygiene and veterinary public health matters to the minister of Interiors, at health; medical products and pharmacovigi- that time responsible for Public Health. lance. According to the regulations in force, the Coun- The Council is asked for advise by the Minister cil is composed of fifty members, appointed by on specific problems related to the above men- the Minister of Health that selects them among tioned matters, that are under the responsibili- the most qualified representatives of the differ- ty of the Ministry of Health. ent medical fields. In addition to the designated Each Section can autonomously express its councillors, the Directors General of the Ministry, advice on items pertaining its own competence, as well as the Directors of the Institutes and but the most important subjects are debated by Agencies that are under the control of the Min- the whole Council in the General Assembly. ister of Health, are also members of the Council. The work of the Council is coordinated by a The Council is subdivided into five Sections, Secretariat headed by a medical Director Gen- respectively competent for – health system eral. Annexes - 345

ANNEX 11: General data on Italy

Administrative Aspects ly coming from other European countries but also from Africa and Asia. At the end of the 1980s Italy is a republic with a written constitution there were an estimated 800 000 illegal immi- dating from 1948. Legislative power is vested in grants living in Italy (Commission of the European the Parliament consisting of two Houses, the Communities 1991), and this number is likely to Chamber of Deputies and the Senate. Members be higher nowadays, especially since Albania of both are elected for five years by universal opened its borders and in view of the situation in and direct suffrage. the countries and territories that formerly made The President of the Republic is elected by a joint up Yugoslavia. This illustrates the extent of the session of the Chamber and Senate for a seven- structural and administrative challenges facing year period. The Prime Minister is appointed by southern European countries. Moreover, while the President and elected by the Parliament. legal immigrants are more likely to be concen- Italy is administratively divided into 19 Regions trated in the wealthy North, estimates indicate and two Autonomous or Self-governing that illegal immigrants remain mainly in the Provinces (Trento and Bolzano, also referred to as poorer South (Council of Europe, 1994b). Trentino Alto Adige) (Fig. 11.1). These Regions have their own governments and councils with Education certain legislative and administrative functions. In addition, Italy is also divided into 103 Provinces In Italy, primary school and secondary school which are responsible for specific and administra- education are compulsory. The number of tive tasks, and further divided into about 8 100 pupils attending senior higher school educa- municipalities. Members of governing Bodies of tion and universities has been increasing Regions, Provinces and Municipalities are all steadily during the past two decades but, elected by universal and direct suffrage. owing to a lack of comparable data, it is not clear whether this represents only bigger birth Household Composition cohorts or a real increase in uptake. However, 74% of the pupils in higher secondary educa- Compared to other southern European coun- tion are in vocational education (Eurostat, tries the average number of people per house- 1995d), a pattern seen only in the countries hold is high, i.e. 2.8 persons per private house- with the most educated workforces (e.g. Den- hold (whilst the average household contains mark, Germany or the Netherlands) (Eurostat, over 3 persons in Greece, Portugal and Spain). 1995c). It is also noteworthy that the propor- Some 47% of households is made up of cou- tion of men and women in higher education ples with children. The percentage of couples are exactly the same (Eurostat, 1995d). without children is the third lowest in the EU. The proportion of people living in single-person Economy households is one of the smallest in the EU but is nevertheless growing (Eurostat, 1995d). Italy has a mixed economy including both private and public sectors. A programme of priva- Migrant Population tization is underway. In the early 1990s: • the agricultural sector was still important, In 1997, official statistics show 1 095 622 for- employing 8% of the workforce although only eigners with resident permits living in Italy, most- accounting for 3.6% of the GDP; 346 - Annexes

Fig. 11.1: Italian Regions Annexes - 347

• industry employed 33% of the population tion in the EU. In 1993, women comprised only and represented 35% of the GDP; 35% of the workforce, one of the lowest pro- • service industries accounted for 53% of the portions among the countries of the EU (Euro- GDP, employing 59% of the population; stat, 1995a). There is also an important under- • tourism represents an important part of the ground economy, which is estimated to gener- Italian economy, recording 51.3 million visitors ate 14-20% of the GDP (Morin, 1995). in 1991 (Hunter 1994), although its seasonal The GDP per head in Italy is about ITL 31 600 nature and the probable large numbers of ille- 000 (most recent estimates) with large varia- gal immigrants working in this area mean that tions among different parts of Italy. The its impact on employment can hardly be Province of Milano has the highest GDP per assessed. head (i.e., ITL 49 610 000) and that of Agri- Unemployment stood at 11.8% of the work- gento the lowest (i.e., ITL 16 530 000). Most force in 1994, and 48% of all unemployed were of the Provinces with lower GDPs are located in under the age of 25, by far the highest propor- Central and Southern Italy. REFERENCES

AAVV. European Allergy White Paper. Allergic Diseases as a Public Health Problem. The UCB Insti- tute of Allergy. Bruxelles, 1997. Adamo B, Stroffolini T, Sagliocca L et al. Ad hoc survey of hepatitis B vaccination campaign in newborns of HbsAg positive mothers and in 12-year-old subjects in Southern Italy. Vaccine, 1998; 16(8): 775-777. Aloisi MS, Girardi E, Ippolito G. Conoscenze e comportamenti sessuali rispetto all’AIDS: rassegna degli studi italiani condotti sulla popolazione giovanile. Ann Ig, 1995; 7: 349-358. ANPA. Secondo rapporto sui rifiuti urbani e sugli imballaggi e rifiuti di imballaggio. Dipartimento Stato dell’Ambiente, Prevenzione, Risanamento e Sistemi Informativi. Rome, 1999. Anversa A, Battisti S, Carreri V et al. Power frequency fields, buildings and the general public: exposure levels and risk assessment. In: Maroni M. ed. Proceedings of the International Confer- ence “Healthy Buildings ’95”. Milano, Italy: 11-14 September 1995: 113-126. Arcà M, Forastiere F, Magliola ME et al. VT/2: La salute? Indagine sullo stato di salute della popolazione. Progetto Salute, 1986; 2: 5-134. Archibald LK, Manning ML, Bell LM et al. Patient density, nurse-to-patient ratio and nosocomial infection risk in a paediatric cardiac intensive care unit. Pediatr Infect Dis J, 1997; 16: 1045-1048. Avramov D. Homelessness in the European Union. Social and legal context of housing exclusion in the 1990s. Brussels, European Federation of National Organizations working with the Homeless – FEANTSA, 1995 (Fourth research report of the European Observatory on Home- lessness). Baldari M, Tamburo A, Sabatinelli G et al. Malaria in Maremma, Italy. Lancet, 1998; 351: 1246- 1247. Belgian Association for Smoking Prevention. Les medécines généralistes et le tabagisme. Newslet- ter, 1989; 4: April-May. Bellini P, Maggiolo G, Spimpolo S et al. La mortalità evitabile nelle UUSSLL del Veneto 1980-88. Giornate di studio sulla popolazione. Bologna, 6-7 Dicembre 1993. Berrino F, Saint M, Verdecchia A et al. eds. Survival of Cancer Patients in Europe. The EUROCARE Study (IARC Scientific Publication, No. n. 132). Lyon, 1995. Bochicchio F, Campos Venuti G, Nuccetelli C et al. Indagine nazionale sulla radioattività naturale nelle abitazioni. Roma, ISS, 1994 (ISTISAN Congressi 34). 350 - References

Borzani M, De Luca M, Varatto F. A survey of susceptibility to erytromycin amongst Streptococcus pyogenes isolates in Italy. J Antimicrob Chemother, 1997; 40: 457-458. Boys RJ, Forster DP. Mortality from causes amenable and non-amenable to medical care: the experience of Eastern Europe. Br Med J, 1991; 303: 879-883. Buiatti E, Barchielli A, Vannucchi G. Eventi-sentinella: esperienze, problemi aperti e prospettive. In: Atti del IV Convegno Nazionale sugli studi di mortalità. Firenze, 12-14 Ottobre 1988. Buiatti E, Acciai S, Ragni P, et al. Dimension of tuberculosis phenomenon in an Italian area and estimate of undernotification through record linkage. Epidemiol Prev, 1998; 22: 237-241. Buratta V, Crialesi R, Faggiano F. Differenze sociali nella salute e tendenze temporali: le indagini ISTAT degli anni ’80. Giornate di studio sulla popolazione. Bologna, 6-7 Dicembre 1993. Campbell GD, Silbermann R. Drug-resistant Streptococcus pneumoniae. Clin Infect Dis, 1998; 26: 1188-1195. Car-Hill RA, Hardman GF, Russel IT. Variations in avoidable mortality and variations in health care resources. Lancet, 1987; April 4: 789-792. Catassi C, Ratsch IM, Fabiani E et al. Coeliac diseases in the years 2000: exploring the iceberg. Lancet, 1994; 343: 200-02. CESES. European Centre for the Epidemiological Monitoring of AIDS. HIV/AIDS Surveillance in Europe: Quarterly Report n. 58. June 1998. http://www.ceses.org. Charlton JRH, Hartley RM, Silver R, et al. Geographical variation in mortality from conditions amenable to medical intervention in England and Wales. Lancet, 1983; March 26: 691-696. COA-ISS. Aggiornamento dei casi di AIDS notificati in Italia al 30 Settembre 1998. Notiziario ISS; Vol. 11, No. 11 (suppl 1), Nov 1998a. COA-ISS. Sorveglianza Nazionale delle malattie sessualmente trasmesse. Rapporto n. 8-Anno 1995. Notiziario ISS; Vol. 11, No. 10, Oct 1998b. Coffey TJ, Daniels M, McDougal LK, et al. Genetic analysis of clinical isolates of Streptococcus pneumoniae with high-level resistance to expanded-spectrum cephalosporins. Antimicrob Agents Chemother, 1995; 39: 1306-1313. Costa G, Faggiano F, Cadum E et al. Le differenze sociali nella mortalità in Italia. In: Costa G, Fag- giano F, eds. L’equità nella salute in Italia. Fondazione Smith Kline, Milano, Franco Angeli, 1994. Costa G, Cardano M, Demaria M. Torino: Storie di salute in una grande città. Città di Torino: uffi- cio di Statistica. Osservatorio socio-economico torinese/2. Torino, 1998. Council of Europe. Recent demographic developments in Europe. Strasbourg, Council of Europe Press, 1994. De Marco R, Zanolin ME. Mortalità per alcune cause riconducibili all’intervento medico nelle ULSS lombarde. Epidemiol Prev, 1990; 45: 24-32. Di Lallo D, Spagnolo A, Patriarca V, et al. Differenze sociali negli esiti dei concepimenti in Italia negli anni ’80. Comunicazione presentata alle giornate di studio sulla popolazione. Bologna, 6-7 December 1993. EC. Commission of the European Communities. Immigration of citizens from Third World countries into the Southern states of the EECC: a comparative survey of the situation in Greece, Italy, Spain and Portugal. Luxembourg, Office for Official Publications of the European Commu- nities, 1991. EC. European Community Atlas on Avoidable Death: 1979-84. Holland WW, ed. Oxford, Oxford University Press/Council of European Communities, 1993. EHLASS. Statistical tables. European Home and Leisure Accident Surveillance System. Brussels, 1995. References - 351

European Registration of Congenital Anomalies. EUROCAT Report 7. 15 years of surveillance of congenital anomalies in Europe 1980-1994. Brussels, Scientific Institute of Public Health Luis Pasteur, 1997. EUROSTAT. Basic statistic of the European Union. Luxembourg, Office for Official Publications of the European Communities, 1995a. EUROSTAT. Education across the European Union-statistics and indicators. Luxembourg, Office for Official Publications of the European Communities, 1995b. EUROSTAT. Eurostat yearbook ’95. Luxembourg. Office for Official Publications of the European Communities, 1995d. EURISKO. La soddisfazione dei cittadini per le prestazioni del Servizio Sanitario Nazionale. Rappor- to 1998. Milano, 1998. Faggiano F, Gnavi R, Lemma P et al. Gli italiani sono uguali davanti alla morte? Giornate di studio sulla popolazione. Bologna, 6-7 Dicembre 1993. Faggiano F, Costa G, Zannetti R. Differenze sociali nell’incidenza dei tumori a Torino. In: Costa G, Faggiano F, eds. L’equità nella salute in Italia. Fondazione Smith Kline. Milano, Franco Angeli, 1994. Fedele D, Comi G, Coscielli C et al. A multicenter study on the prevalence of diabetic neuropathy in Italy. Italian Diabetic Neuropathy Committee. Diabetes Care, 1997; 20 (5): 836-843. Ferraroni M, La Vecchia C, Pagano R et al. Pattern of cervical screening utilization in Italy. Tumori, 1989; 75: 420-422. Garcia-Bermejo I, Cacho J. Emergence of erytromycin-resistant, clindamycin-susceptible Streptococ- cus pyogenes isolated in Madrid, Spain. Antimicrob Agents Chemother, 1998; 42: 989-990. Geddes M Ed. Rapporto sulla salute in Italia. Salute e sistami sistemi sanitari nell’Unione Europea. Roma, Ediesse, 1995. Giuliani M, Suligoi B, and the STD Surveillance Working Group. Sentinel surveillance of sexually transmitted diseases in Italy. Eurosurveillance, 1998; 3(6). Greco L, Maki M, Di Donato F, et al. Epidemiology of coeliac disease in Europe and the Mediterre- nean area. In: Auricchio S, Visakorpi eds. Common food intolerances 1: Epidemiology of coeliac disease. Dynamic Nutrition Research. Basel. S Karger AG; 1992: 25-44. Grodzinsky E, Franzen L, Hed J, et al. High prevalence of coeliac disease in healthy adults revealed by antigliadin antibodies. Ann Allergy, 1992; 69: 66-70. Hanberger H, Garcia-Rodriguez JA, Gobernado M, et al. Antibiotic susceptibility among aerobic Gram-negative bacilli in intensive care units in 5 European countries. JAMA, 1999; 281(1): 67-71. Heise LL. Violence against women: the Hidden Health burden. Washington DC, World Bank, 1994 (Discussion Paper, No.255). 1994. Hoge CW, Gambel JM, Srijan A, et al. Trends in antimicrobial resistance among diarrheal pathogens isolated in Thailand over 15 years. Clin Infect Dis, 1998; 26: 341-345. Houweling H, Downs AM, Rava L, et al. Epidemiological impact of HIV/AIDS in the European Union study for the EU concerted action on multinational AIDS scenarios. 12th International Con- ference on AIDS. Geneva, June-July 1998 [abstract 13182]. ICONA-ISS Working Group. Indagine sulla copertura vaccinale infantile. Roma, ISS, 1999 (Rappor- ti ISTISAN), in press. ILO. Year book of labour statistics. 53rd issue. Geneva, International Labour Office, 1994. ILSA, The Italian Longitudinal Study on ageing working group. Prevalence of chronic diseases in older Italians: comparing self-reported and clinical diagnoses. Int J Epidemiol, 1997; 26: 995-1002. 352 - References

ISAAC. Worldwide variations in the prevalence of asthma symptoms: the International Study of Asthma and Allergies in Childhood. Eur Respir J 1998; 12: 315-335. ISTAT. La mortalità differenziale secondo alcuni fattori socio-economici 1981-82. Note e Relazioni, 2. Roma, ISTAT, 1990. (Note e Relazioni, No. 2). ISTAT. Condizione di salute e ricorso ai servizi sanitari. Indagine multiscopo sulle famiglie, Anni 1987-91, No. 10. Roma, ISTAT, 1994a. ISTAT. Gli incidenti in ambiente domestico. Indagine multiscopo sulle famiglie, Anni 1987-91, No 3. Roma, ISTAT, 1994b. ISTAT. I disabili. Indagine multiscopo sulle famiglie, anni 1987-91, No. 11. Roma, ISTAT, 1995. ISTAT. Rapporto annuale. La situazione del Paese nel 1995. Roma, ISTAT, 1996a. ISTAT. Previsioni della popolazione residente per sesso, età e regione. Base 1-1-1996. ISTAT Infor- mazioni n. 34. Roma, ISTAT, 1997a. ISTAT. Anziani in Italia. Bologna, Il Mulino, 1997b. ISTAT. Cause di morte. 1994. Roma, ISTAT, 1997c. ISTAT. L’interruzione volontaria di gravidanza in Italia. Argomenti No.9. Roma, ISTAT, 1997d. ISTAT. Gli incidenti stradali negli anni ’90. Argomenti No. 7. Roma, ISTAT, 1997e. ISTAT. Rapporto sull’Italia edizione 1997. Bologna, Il Mulino, 1997f. ISTAT. Rapporto annuale. La situazione del Paese nel 1997. Roma, ISTAT, 1998a. ISTAT. Compendio Statistico Italiano, 1998. Roma, ISTAT, 1998b. ISTAT. La vita quotidiana nel 1996. Informazioni No. 60. Roma, ISTAT, 1998c. Jarlier V, Fosse T, Philippon A, ICU Study group. Antibiotic susceptibility in aerobic Gram-negative bacilli isolated in intensive care units in 39 French teaching hospitals (ICU Study) Intensive Care Med, 1996; 22: 1057-1066. Karvonen M, Jantti V, Muntoni S, et al. Comparison of the seasonal pattern in the clinical onset of IDDM in Finland and Sardinia. Diabetes Care, 1998; 21 (7): 1101-9. Kogevinas M, Marmot MG, Fox AJ, et al. Socio economic differences in cancer survival. J Epidemi- ol Community Health, 1991; 45: 216-219. Kunst AE et al. An international comparison of socioeconomic inequalities in mortality. MGZ. 92.11. Department of Public Health and Social Medicine. Rotterdam, Erasmus University, 1992. Lagorio S, Comba P, Iavarone I, et al. Tumori e malattie neurodegenerative in relazione alla espo- sizione a campi elettrici e magnetici a 50/60Hz: Rassegna degli studi epidemiologici. Rap- porto ISTISAN 98/31, 1998. Last JM. A Dictionary of Epidemiology . Second Edition. Oxford, Oxford University Press, 1988. Lauriola P, Goldoni CA. Osservazioni, commenti e proposte su un’indagine condotta nella regione Emilia-Romagna nel 1987 su alcuni eventi sentinella. Epidemiol Prev, 1989; 39: 22-28. La Vecchia C, Negri E, Pagano R, et al. Education, prevalence of disease and frequency of health care utilisation. The 1983 Italian National Health Survey. J Epidemiol Community Health, 1987; 41: 161-165. Livermore DM. Beta lactamases in laboratory and clinical resistance. Clin Microbiol Rev, 1995; 8: 557-584. London School of Hygiene and Tropical Medicine (LSHTM)/WHO. Childhood Injuries: A priority area for the transition countries of Central and Eastern Europe and the Newly Independent States. Final Report. London, UK, September 1998. Mackenbach JP, Kunst AE, Looman CWN et al. Regional differences in mortality from conditions amenable to medical intervention in The Netherlands: a comparison of 4 time-periods. J Epi- demiol Community Health, 1988; 42: 325-332. References - 353

Mackenbach J et al. Socioeconomic inequalities in mortality and morbidity in Western Europe. Lancet, 1997; 349: 1655-1659. Maki M, Collin P. Coeliac disease. Lancet, 1997; 349: 1755-1759. Marshall SW, Kawachi I, Pearce N, et al. Social class differences in mortality from diseases amenable to medical intervention in New Zealand. Int J Epidemiol, 1993; 22: 255-261. McMillan SA, Watson RPG, McCrum EE, et al. Factors associated with serum antibodies to reticulin, endomysium, and gliadin in an adult population. Gut, 1996; 39: 43-47. Mele A, Stroffolini T, Palumbo F, and the SEIEVA Collaborating Group. Incidence of and risk factors for hepatitis A in Italy: public health indications from a 10-years surveillance. J Hepatol, 1997; 26: 743-747. Michelozzi P, Perucci CA, Forastiere F, et al. Inequality in health: increasing socio-economic differ- entials in mortality in Rome, 1990-1995. J Epidemiol Community Health, in press. Ministry of Environment of Italy. Relazione sullo stato dell’ambiente. Roma, Ministero dell’Ambi- ente, 1997. Ministry of Internal Affairs of Italy. Anti-drug Central Service, Report 1997. Roma, Ministero degli Interni, 1997. Ministry of Health of Italy. Relazione sullo stato sanitario del paese 1996. Roma, Servizio Studi e Documentazione Ministero della Sanità, 1996. Ministry of Health of Italy. 1996 Report. Roma, Public Health Department Ministero della Sanità Roma, July 1997. Ministry of Health of Italy. Piano Sanitario Nazionale 1998-2000. Roma, Ministero della Sanità, 1998. Ministry of Health of Italy. Malinf Epidemiological Bullettin. http://www.sanita.interbusiness.it/malinf/english/bollepid/index.htm. 1999a. Ministry of Health of Italy. Qualità delle acque di balneazione. Rapporto numerico. Roma, Ministero della Sanità, 1999b. Ministry of Health of Italy. Relazione sullo stato sanitario del paese 1998. Roma, Servizio Studi e Documentazione Ministero della Sanità, 1999c, in press. Morin J. El trabajo clandestino se convierte en el motor principal de la economia sumergida en Europa. Fuentes estadisticas, 1995; 7. Murray CJL and Lopez AD. Global Health Statistics, Global Burden of Disease and Injury Series, Vol. II. Boston, MA, Harvard School of Public Health. Boston, MA, 1996. NIEHS Working Group Report. Assessment of health effects of exposure to power-line frequency electric and magnetic fields. Portier C J, Wolfe M S, eds. National Institute of Environmen- tal Health Sciences of the National Institute of Health. Research Triangle Park, NC, August 1998. OECD/CREDES. OECD Health Data, 1998. Paris, 1998. OER (Lazio Region Epidemiology Unit). Rapporto del sistema informativo della natalità e mortalità infantile nel Lazio. Anni 1993-94. Progetto Salute, 1998; n. 40. Perucci CA, Rapiti E, Davoli M et al. Rome women screening study: knowledge, attitudes and practices of women regarding screening for breast and cervical cancer. Tumori, 1990; 74: 365-369. Petruccelli BP, Murphy GS, Sanchez JL, et al. Treatment of traveler’s diarrhea with ciprofloxacin and loperamide. J Infect Dis, 1992; 165: 557-560. Piddock LJV. Quinolone resistance and Campylobacter spp J. Antimicrob Chemother, 1995; 36: 891-898. Poikolanen K, Eskola J. Health services resources and their relation to mortality from causes amenable to health care intervention: a cross-national study. Int J Epidemiol, 1986: 86-89. 354 - References

Ponti A. Abitudini di vita a Torino. Prevalenza, associazioni con lo stato sociale, evidenza di possi- bili conseguenze allo stato di salute. Tesi di specializzazione in igiene e medicina preventi- va. Torino, Università degli studi, 1989. Ponti A, Faggiano F. La distribuzione sociale dei fattori di rischio di malattia: il caso del fumo di tabacco. In: Costa G, Faggiano F, eds. L’equità nella salute in Italia. Fondazione Smith Kline, Milano, Franco Angeli, 1994. Porta M, Tomalino MG, Santoro F et al. Diabetic retinopathy as a cause of blindness in the province of Turin, North-West Italy, in 1967-1991. Diabet Med, 1995; 12 (4): 355-361. Pradier C, Dunais B, Carsenti-Etesse H, et al. Pneumococcal resistance in Europe. Eur J Clin Micro- biol Infect Dis, 1997; 16: 644-647. Prospero E, Appignanesi R, D’Errico MM, et al. Epidemiology of tetanus in the Marches Region of Italy, 1992-95. Bulletin of the World Health Organization, 1998; 76 (1): 47-54. Robine, JM, Romieu I. Monitoring health inequalities in Europe: the need for health surveys. Working paper prepared for the Fourth Consultation on Common Methods and Instruments for Health Interview Surveys in Europe, Copenhagen, 26-28 February, 1997. (Document EUR/ICP/INFO 02 03 0518). Ronco G, Segnan N, Ponti A. Who has pap test? Variables associated with the use of pap test in absence of screening programmes. Int J Epidemiol 1991; 20: 349-350. Rutstein DD, Berenberg W, Chalmers TC et al. Measuring the quality of medical care. N Engl J Med, 1976; 294 (11): 582-588. Scafato E. Review of the results of the EAAP in Italy in 1992-1998. Roma, Ministry of Health of Italy - ISS internal document, 1998. SEIEVA-ISS. Sorveglianza epidemiologica dell’epatite virale acuta. Notiziario ISS, Oct 1998; Vol 11, No. 10 (suppl 1). Silano M, De Vincenzi M. In vitro screening of food peptides toxic for coeliac and other gluten-sensitive patients: a review. Toxicology, 1999; 132 (2-3): 99-110. Shultz Larsen F. The epidemiology of atopic dermatitis. In: Burr M.L. eds. Epidemiology of Clinical Allergy. Monogr Allergy, Basel, Karger 1993; 31: 9-28. SIDRIA Collaborative group. Studi Italiani sui disturbi respiratori nell’infanzia e l’ambiente (SIDRIA). Epidemiol Prev, 1995; 19: 76-78. SIDRIA Collaborative group. La frequenza dell’asma pediatrico in diverse aree italiane. I risultati di SIDRIA. Epidemiol Prev, 1997; 21: 235-242. SIDRIA. Collaborative group. La frequenza dei fattori di rischio per l’asma bronchiale in varie aree italiane. Epidemiol Prev, 1997; 21:243-251. 1997b. SIDRIA. Collaborative group. Abitudine al fumo di sigarette tra gli studenti di III media in diverse aree italiane. Epidemiol Prev, 1998; 2: 155-164. Sjolie AK, Stephenson J, Aldington S et al. Retinopathy and vision loss in insulin-dependent diabetes in Europe. The EURODIAB IDDM Complications study. Ophthalmology, 1997; 104 (2): 252-260. Songini M. Epidemiology of IDDM: recent advances. J Pediatr Endocrinol Metab, 1998; 11( suppl. 2): 319-326. Spinelli A, Grandolfo ME, Pediconi M et al. L’interruzione di gravidanza in Italia: 1991-1992. ISS, Roma, 1995 (Rapporto ISTISAN; No. 95/22). Threlfall FJ, Ward BR, Skinner JA, et al. Increase in multiple antibiotic resistance in non typhoidal salmonellas from humans in England and Wales: a comparison of data for 1994 and 1996. Microb Drug Resist, 1997; 3: 263-266. Toscana Region, Statistics Department. La mortalità per condizione socio-economica e profession- ale nello studio longitudinale toscano, Comuni di Livorno e Firenze. Informazioni statistiche, studi e ricerche. Firenze, 1998. References - 355

Trautner C, Icks A, Haastert B, et al. Incidence of blindness in relation to diabetes. A population- based study. Diabetes Care, 1997; 20 (7): 1147-53. UNDP. Human Development Report 1997. Oxford, Oxford University Press, 1997. UNDP. Human Development Report 1998. Oxford, Oxford University Press, 1998. UNICEF. The State of the World’s Children 1998. Oxford, Oxford University Press, 1998 Vagero D, Persson G. Cancer survival and social class in Sweden. J Epidemiol Community Health, 1987; 41: 204-209. Valkonen T. Le ineguaglianze sociali nella salute nei paesi europei: testimonianze e tendenze. In: Costa G, Faggiano F, eds. L’equità nella salute in Italia. Fondazione Smith Kline, Milano, Franco Angeli. 1994. Van Reek J, Adriaanse H, Knibbe R. Alcohol consumption and correlates among children in the European Community. Int J Addict, 1994; 29 (1): 15-21. Verdecchia A, Micheli A, Gatta G, Eds. Survival of Cancer patients in Italy. The ITACARE study. Tumori, 1997; 83: 1-508. Vincent H, Bihari DJ, Suter PM, et al. The prevalence of nosocomial infection in intensive care units in Europe. JAMA, 1995; 274: 639-644. Voss A, Milatovic D, Wallrauch- Schwartz C, et al. Methicillin-resistant Staphilococcus aureus in Europe. Eur J Clin Microbiol Infect, 1994; 13: 50-55. WHO. The health of youth. A report of the 1993/1994 survey results of Health health Behaviour behaviour in Schoolschool-Aged aged Childrenchildren: a WHO Cross-National Study. Copenhagen, WHO Regional Office for Europe, 1996 (WHO Regional Publications, European Series, No. 69). WHO. 1995 World Health Statistics Annual. Geneva, 1996b. WHO. Smoking, drinking and drug taking in European Region. Copenhagen, WHO Regional Office for Europe, 1997a. WHO. World drink trends. Schediam, Produktschap voor Gedistilleerde Dranken, Copenhagen, WHO Regional Office for Europe, 1997b. WHO. European Health care Reform. Copenhagen, WHO Regional Office for Europe, 1997c. (WHO Regional Publications, European Series, No. 72). WHO. The World Health Report 1998. Geneva, 1998a. WHO. Health in Europe 1997. Copenhagen, WHO Regional Office for Europe, 1998b (WHO Regional Publication, European Series, No. 83). WHO. Highlights on Health in Italy. Copenhagen, WHO Regional Office for Europe, 1998c. WHO. The World Health Report 1999. Geneva, 1999a. WHO. Health21. The Health for All policy framework for the WHO European Region. Copenhagen, WHO Regional Office for Europe, 1999b. WHO. HFA Database. January 1999 version. Copenhagen, WHO Regional Office for Europe, 1999c. WHO. Overview of the Environment and Health in Europe in the 1990s. Background document. Third Ministerial Conference on Environment and Health, London, 16-18 June 1999. Copenhagen, WHO Regional Office for Europe, 1999d, in press. WHO. International EMF Project. http://www.who.int/inf-fs/en/fact183.html. 1999e. WHO-ECEH. Concern for Europe’s Tomorrow. WHO. Stuttgart, Wissenschaftliche mbtt, 1995. WHO-ECEH. Ambiente e Salute in Italia. Bertollini R, Faberi M, Di Tanno N, eds. Roma, Il Pensiero Scientifico, 1997. WHO-ECEH. http://www.who.dk/envhlth/airqual.htm#d. 1999. WHO-ECEH/ITARIA Group. Inquinamento Atmosferico: l’applicazione di modelli per la descrizione della qualità dell’aria e valutazione dell’impatto sulla salute delle diverse situazioni a rischio. First progress report. Internal document, Roma, 1999. 356 - References

WHO-ECEH/ITARIA http://www.arpa.emr.it/itapub/ita/main.asp, 1999b. WHO-FAO. WHO Surveillance Programme for Control of Foodborne Infections and Intoxications in Europe. Sixth Report 1990-1992. Berlin, Institute of Veterinary Medicine, Robert von Ostertag Institute, 1995. Zanetti R, Crosignani P, Rosso S, eds. Il cancro in Italia, i dati di incidenza dei registri tumori. Se- condo volume 1988-1992. Roma, Il Pensiero Scientifico, 1997. Zanetti R, Buiatti E, Federico M, et al. Fatti e cifre dei tumori in Italia. Roma, Il Pensiero Scientifico, 1998.