Bhc Baseline Study

Building Healthy Communities

The Baseline Study

October 2008

Contents

I. Health and Quality of Life: A State of the Art …………… p. 1

II. The Partner Cities ………………………………………… p. 13 Amaroussion ……………………………………………… p. 16 Bac ău ……………………………………………………… p. 33 Baia Mare …………………………………………………. p. 50 Barnsley …………………………………………………… p. 65 Belfast ……………………………………………………... p. 74 Lecce ………………………………………………………. p. 86 Lidingö …………………………………………………….. p. 95 Łodz ……………………………………………………….. p. 106 Madrid ……………………………………………………... p. 113 Torino ……………………………………………………… p. 132

III. Health and Quality of Life in EU Cities: A Synthesis ……… p. 149

This report has been elaborated by Marco SANTANGELO – BHC Lead Expert

I. Health and Quality of Life: A State of the Art

In Europe

On the European stage the EU, and especially the European Commission through the DG SANCO, is active in health promotion and linking issues of the environment and health policies together.

“We need to ensure that health is at the very heart of policy making at regional, national and EU level. We need to promote health through all policies. Policy measures as different as inner city development, regional transport infrastructure, applied research, air pollution, or international trade must take health into account. Health needs to be integrated into all policies, from agriculture to environment, from transport to trade, from research to humanitarian aid and development .” (Byrne, 2004 1)

Improving quality of life and good health is the EU major goal, and it is achievable by approaching it from a broad perspective. While acknowledging the role of Member States in this policy area, the EU do not proposes legislation at European level, just raises awareness of the issue. Under the EU Treaty (Treaty of Amsterdam, 1997), actions must aim to improve public health, prevent human illness and diseases and identify sources of danger to human health. This has led to integrated health-related work at EU level , aiming to bring health related policy areas together. Article 152 of the Treaty is, in fact, concerned with public health when it says:

“A high level of human health protection shall be ensured in the definition and implementation of all Community policies and activities. Community action [...] shall be directed towards improving public health, preventing human illness and diseases, and obviating sources of danger to human health ”.

Through the Health Strategy, the EU plays its part in improving public health in Europe. The role of the EU is to support Member States in their actions of public health and to assist national decision making. Thus, EU action focuses on strengthening cooperation and coordination, supporting the exchange of evidence-based information and knowledge. Public authorities in Member States have a responsibility to ensure that these concerns are reflected in their policies. In addition, the European Union has a vital role to play through the obligations placed on it by the European Treaties. Community actions complement the Member States’ national health policies, but at the same time bring European added value: issues such as cross-border health threats – for example influenza - or free movement of patients and medical personnel need a response at European level.

On 23 October 2007 the European Commission adopted a new Health Strategy, “Together for Health: A Strategic Approach for the EU 2008-2013 ”. This Strategy

1 Byrne D. (2004), Enabling good health for all. A reflection process for a new EU health strategy , EC – DG Health and Consumer Protection, Bruxelles.

aims to provide, for the first time, an overarching strategic framework spanning core issues in health as well as health in all policies and global health issues. The Strategy aims to set clear objectives to guide future work on health at the European level, and to put in place an implementation mechanism to achieve those objectives, working in partnership with Member States. The Strategy focuses on four principles and three strategic themes for improving health in the EU. The principles include: - taking a value-driven approach; - recognising the links between health and economic prosperity; - integrating health in all policies; - strengthening the voice of the EU in global health.

The strategic themes include: - fostering good health in an ageing Europe; - protecting citizens from health threats; - dynamic health systems and new technologies.

The Health Programme is the key means to implement health objectives at European level. The “ Second Programme of Community Action in the Field of Health 2008- 2013 ” follows the first Programme of Community action in the field of public health (2003-2008) which financed over 300 projects and other actions. The Health Programme is based on Article 152 of the Treaty establishing the European Community. It is an incentive measure designed to protect and improve human health, excluding any harmonisation of the laws and regulations of the Member States. The Health Programme 2008-2013 is intended to complement, support and add value to the policies of the Member States and contribute to increased solidarity and prosperity in the European Union by protecting and promoting human health and safety and by improving public health. The Programme objectives are: To improve citizens’ health security: • Developing EU and Member States’ capacity to respond to health threats, for example with health emergency planning and preparedness measures; • Actions related to patient safety, injuries and accidents, risk assessment and community legislation on blood, tissues and cells. To promote health, including the reduction of health inequalities: • Action on health determinants - such as nutrition, alcohol, tobacco and drug consumption, as well as social and environmental determinants; • Measures on the prevention of major diseases and reducing health inequalities across the EU; • Increasing healthy life years and promoting healthy ageing. Health information and knowledge: • Action on health indicators and ways of disseminating information to citizens; • Focus on Community added-value action to exchange knowledge in areas such as gender issues, children's health or rare diseases.

Health in all policies to highlight the relationship between health and wealth

Many Community policies and actions have an impact on health and health systems across Europe. They are often developed within a different policy logic and decision makers are often not well aware of potential health effects. Important health determinants cannot be influenced by health policy on its own; there is a need for co-ordinated actions involving other policy areas such as environmental, social or economic policies . To this purpose, it is essential to take into account the Lisbon Agenda, being this the key EU policy on economic growth and productivity, and to mainstream health into the Lisbon Agenda is one of the most important achievements of mainstreaming health into other policies. The link between health and economic prosperity is more and more widely recognised, in particular in relation to the ageing population (the Healthy Life Years indicator, a measure of years lived in good health, being the only European Structural Indicators of the Lisbon Agenda that directly relates to health). The Finnish Ministry of Health and Social Affairs has taken forward the up the theme of Health in All Policies as part of its 2006 Presidency of the European Union. With co- funding from the Community Public Health Programme the Presidency co-ordinated a project entitled “Europe for health and wealth”, which consists of influencing determinants of health in other national and Community policies and gathering the best available knowledge on good practices to engage other sectors in improving health and reducing health inequalities. To this purpose, also the latest relevant document on this issue, “The contribution of health to the economy in the European Union” (2005), must be taken into account, since “There is a sound theoretical and empirical basis to the argument that human capital contributes to economic growth. Since human capital matters for economic outcomes and since health is an important component of human capital, health matters for economic outcomes. At the same time, economic outcomes also matter for health” (p.9) 2.

Lifestyle

Lifestyle related health determinants are multi-dimensional. These determinants are linked to number of major health problems. Also, some health issues share same determinants such as tobacco, alcohol, and nutrition. Health problems linked to lifestyle related health determinants can be life-situation specific (e.g. in childhood or in old age) but they can also be strongly linked to cultural aspects. In addition, socio-economic factors are an important reason for variations in health. Addressing these factors is considered as important in the framework of the EU Health Strategy, and a

2 http://ec.europa.eu/health/ph_overview/Documents/health_economy_en.pdf

comprehensive health promotion in various settings (e.g. schools, workplaces, families and local communities) has proven to be efficient in addressing health determinants.

Health inequalities and socio-economic determinants of health

Health inequalities lower the ability of huge numbers of EU citizens to achieve their potential. Action to reduce health inequalities aims: - to improve everyone’s level of health closer to that of the most advantaged; - to ensure that the health needs of the most disadvantaged are fully addressed; - to help the health of people in countries and regions with lower levels of health to improve faster.

At the EU level this involves many policy areas including: - Economic, employment and social policy - through the Lisbon process to strengthen the European economy and at the same time ensure social protection and measures to improve social inclusion. - Regional Policy - to support the economies and health infrastructure of countries and regions of the EU which are lagging behind or have special needs. - Research - to identify the causes of socio-economic health inequalities and to develop and evaluate measures to combat them - Public Health - action to reduce health inequalities is an overall aim and objective of the public health action programme 2007-2013.

Environment

The presence of natural or man-made hazards is a source of environmental diseases, which might be seen as the visible and clinical indication of inadequate environmental conditions. Key areas of action could be: • Outdoor and indoor air pollutants quality, • Noise • Indoor environment and housing conditions, • Water quality contamination, • Electromagnetic fields and radiation, • Chemical exposures.

The impact of these factors are felt in association with hearing problems, sleeping disorders, stress leading to hypertension and other circulatory diseases, skin and other cancers, asthma, or birth defects.

The WHO role

WHO action in public health policies – especially referring to the WHO European Regional Office – goes hand in hand with EU policy developments. Since health habits and outcomes of health behaviour are highly affected by other social-economic circumstances, in 2005 the Director General of the WHO set up a global commission on the “Social Determinants of Health”. The objective of the commission was to achieve

policy change by learning from existing knowledge about the social determinants of health and turning that learning into global and national political and economic action3. According to the definition given by WHO:

“[h]ealth is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief or economic and social condition ” 4.

Not only does this statement define health, it is evidence of the public health pendulum swinging away from a medical model and back towards a social model – the new public health paradigm . The medical model focuses on the individual and on interventions that are used to treat disease. By contrast, a social model considers health as an outcome of the effects of socio-economic status, culture, environmental conditions, housing, employment and community influences. This perspective conveys the breadth of public health and the need for health, in the broadest sense, to be considered in development processes and in policy-making. Its tenets are as follows: 1. health is not merely the absence of disease or disability; 2. health problems are defined at the policy level; 3. health is a social issue; 4. improving health status requires a long-term focus on policy development; 5. improving health status requires a primary focus on changing basic conditions; 6. improving health status requires involving natural leaders in the process of change.

Good health is, in fact, something which everyone wants – for themselves, their children and for the wider economic and social benefits it brings to our society. It plays a major role in long-term economic growth and sustainable development. This is especially true in urban areas, where the environmental, economic and social dimensions meet most strongly. Cities are where many environmental, economic and social problems are concentrated, but they are also the national economic drivers, the places where business is done and investments are made. Four out of five European citizens live in urban areas, and their quality of life, well-being and health is directly influenced by the state of the urban environment, economic and social factors . The attractiveness of European cities will enhance their potential for growth and job creation, and cities are therefore of key importance to the implementation of the Lisbon Agenda 5. At the United Nations World Summit on Sustainable Development in Johannesburg (South Africa, 2002) WHO identified urbanization as a key challenge for health and

3 http://www.who.int/social_determinants/en/. 4 Preamble to the Constitution of the World Health Organization, as adopted by the International Health Conference, New York, 19 June - 22 July 1946. Signed on 22 July 1946 by the representatives of 61 States (Official Records of the World Health Organization, no. 2, p. 100) and entered into force on 7 April 1948. The definition has not been amended since 1948. 5 European Commission (2006), Cities and the Lisbon Agenda: Assessing the performance of cities , EC – DG Regional Policy, Bruxelles (http://www.eukn.org/binaries/eukn/eukn/research/2006/2/cities-and-the-lisbon- agenda.pdf; visited on the 15 th of October 2007).

sustainable development , along with poverty, global environmental change, globalisation and disasters. Air pollution, noise, overcrowded housing, and inadequate water and sanitation – considered as characteristics of urban areas – continue to be major contributors to bad health in Europe, particularly among migrants, children, women and elderly people. Differences in health condition, then, arise from differences in the factors that influence health. These factors, that refers to many different conditions, can be summarised as: - age, sex and hereditary factors; - individual lifestyle factors; - social and community influences; - living and working conditions; - general socio-economic, cultural and environmental conditions.

Some of these factors cause differences that cannot be avoided. Differences in gender and/or in age can result, for example, in differences in health conditions, but sometimes improvements arise if specific measures are adopted. WHO uses equity and inequity to refer to “differences in health which are not only unnecessary and avoidable but, in addition, are considered unfair and unjust”. “Equity is [...] concerned with creating equal opportunities for health and with bringing health differentials down to the lowest possible” 6.

Approaches that are used to reduce inequity in health can be broadly divided into four different measures that: a) strengthen individuals; b) strengthen communities; c) improve access to essential facilities and services; d) encourage macroeconomic and cultural change.

A programme to address inequity in health and in quality of life conditions will require initiatives at all four levels.

Health as a resource

As per the “Ottawa Charter for Health Promotion” (17-21 Nov. 1986), health promotion is the process of enabling people to increase control over, and to improve, their health. To reach a state of complete physical mental and social well-being, an individual or group must be able to identify and to realize aspirations, to satisfy needs, and to change or cope with the environment. Health is, therefore, seen as a resource for everyday life , not the objective of living. Health is a positive concept emphasizing social and personal resources, as well as physical capacities. Therefore, health promotion is not just the responsibility of the health sector, but goes beyond healthy lifestyles to well-being. Good health is a major resource for social, economic and personal development and an important dimension of quality of life. Political, economic, social, cultural, environmental, behavioural and biological factors can all favour health or be harmful to it. Health promotion action aims at making these conditions favourable through

6 WHO Glossary created by Ruth Barnes and the Health Development Agency (http://www.who.int/hia/about/glos/en/index.html) (web site consulted on the 15th of October 2007).

advocacy for health. Health promotion generates living and working conditions that are safe, stimulating, satisfying and enjoyable. The responsibility for health promotion in health services is shared among individuals, community groups, health professionals, health service institutions and governments. They must work together towards a health care system which contributes to the pursuit of health. The role of the health sector must move increasingly in a health promotion direction, beyond its responsibility for providing clinical and curative services. Health services need to embrace an expanded mandate which is sensitive and respects cultural needs. This mandate should support the needs of individuals and communities for a healthier life, and open channels between the health sector and broader social, political, economic and physical environmental components.

The importance of the urban dimension

Given the general context provided by the WHO, the EU and other national and international agencies, specific attention should be paid to the urban level and to quality of life in the cities. This has also been highlighted in the Leipzig Charter, in which it is stated that: “all dimensions of sustainable development should be taken into account at the same time and with the same weight. These include economic prosperity, social balance and a healthy environment. At the same time attention should be paid to cultural and health aspects. […] Our cities possess unique cultural and architectural qualities, strong forces of social inclusion and exceptional possibilities for economic development. They are centres of knowledge and sources of growth and innovation. At the same time, however, they suffer from demographic problems, social inequality, social exclusion of specific population groups, a lack of affordable and suitable housing and environmental problems ” (p. 1) 7.

The Charter also recommend to make greater use of integrated urban development policy approaches by: - creating and ensuring high-quality public spaces; - modernize infrastructure networks and improving energy efficiency; - proactive innovation and educational policies.

In this framework specific attention has to be paid to deprived neighbourhoods within the context of the city as a whole, especially by: - pursuing strategies for upgrading the physical environment; - strengthening the local economy and the local labour market policy; - proactive education and training policies for children and young people; - promotion of efficient and affordable urban transport.

7 www.eu2007.de/en/News/download_docs/Mai/0524-AN/075Dokument Leipzig Charta.pdf

coordinated action among the EU, the national, the regional and the local level in the field of health and health related policies. Conditions in cities, sometimes compounded by urban planning practices, can be in fact detrimental to health. Healthy urban planning focuses on the positive impact that urban planning can have on human health, well-being and quality of life, and reflects WHO's broad definition of health. The health and well-being of any population requires a holistic approach that includes the involvement of many agencies and gives ownership to the communities involved. The traditional notion of top-down delivery of health care is no longer acceptable to central governments, who are seeking greater value for money, or – from another point of view – who are continuously reducing the amount of budget for local authorities. In the same time, the increasing return to the principles of public health signifies that a purely medical approach to health cannot by itself resolve the many health problems in increasingly complex cities. Government health strategy documents increasingly recognize the importance of the views of the people receiving services in needs-based service delivery and espouse the involvement of individuals and communities as a key objective in the future delivery of health services. To give people an effective voice in the shaping of the health services there needs to be a move away from one-off consultation towards ongoing involvement of local people. Healthy urban planning, in the simplest terms, should mean planning that (a) is not unhealthy and (b) promotes health. Factors affecting urban planning and health include: - high priority of urban planning and health in the political agenda; - monitor pollution level (air, water, outside and inside air pollution, etc.) and maintaining pollution under control; - plan, design and build urban areas focusing on people’s health (green areas, housing, availability and accessibility of health and social services, etc.).

Planners must fully recognize the importance of housing environments, but an appreciation of the social and ecological consequences for the whole community is fundamental. For example, the spacious single-family home on a large lot may meet the needs of a single family, but such a solution is not feasible on a global level. When considering healthy housing design, it is necessary to strike a balance between the needs of the individual, of the family and of the larger community. Learning from mistakes, made in previous efforts to provide quality housing, is another vital component of healthy planning. Urban renewal was intensely popular in the 1960s and 1970s in North America and Europe. Between 1964 and 1974, the London County Council built 384 high towers with the intention of providing quality housing and less oppressive conditions for the economically disadvantaged . This practice is also known as “slum clearance.” The results have been a failure: in fact, some communities were found to be stronger, more vibrant and more hopeful prior to their dislocation. Dwelling types have also been linked to feelings of loneliness and isolation, particularly among the elderly and women. Such feelings of isolation are at their extreme among those living in high rises that are social housing projects, for these people have no other choice but to live in a place that isolates residents from one another and from the outside world based on their socio-economic status. To save costs, the design of each dwelling unit has often been repetitive, not taking into account the specific needs of a diversity of individuals, families and social activities. Isolation is intensified by the fact that social housing projects often look very similar and are easily identifiable, thus

heightening the social stigma along with the increased feelings of loneliness among residents. Forcing people to live where they do not want to be and where they have not been given the opportunity to contribute to the process is essentially a recipe for social chaos in several EU cities. “Public spaces become barren zones where gangs wage war.” 8 If a community does not have adequate health services, schools, libraries, recreational facilities or access to food and parks, the community loses a major buffer against violence. Without these critical institutions, not only is a buffer missing, but there is no community infrastructure and thus minimal opportunity for community cohesion, resulting in intensified fragmentation. This places urban planners in a position of great importance. It stresses the need for creating neighbourhoods that foster pride, respect and friendliness and ensure accessibility of services. It provides evidence of the importance of “liveable urban spaces located at the heart of the city or neighbourhood … [That] exemplify the essence of the community” 9. There are, of course, many different opinions as to what constitutes a healthy city, depending upon one’s discipline, values and point of view. Nevertheless, general principles, theories and common parameters can be applied in working towards healthy urban planning.

An healthy city should then focus on: - equity . All people must have the right and the opportunity to realize their full potential in health; - health promotion . A city health plan should aim to promote health by using the principles outlined in the “Ottawa Charter for Health Promotion” (17-21 Nov. 1986): build healthy public policy; create supportive environments; strengthen community action and develop personal skills; reorient health services; - inter-sectoral action . Health is created in the setting of everyday life and is influenced by the actions and decisions of most sectors of a community; - community participation . Informed, motivated and actively participating communities are key elements for setting priorities and making and implementing decisions; - supportive environments . A city health plan should address the creation of supportive physical and social environments. This includes issues of ecology and sustainability as well as social networks, transportation, housing and other environmental concerns.

8 Duhl L. J. and Sanchez A. K. (1999), “Healthy cities and the city planning process”, WHO Regional Office for Europe, Copenhagen. 9 Cohen L. (1993), “A public health approach to the violence epidemic in the United States”, Environment and urbanization, 5, pp. 50–66.

collaborative and bottom-up actions. Healthy urban planning thus makes room for citizens as leaders and requires catalytic leadership from planners. Disadvantaged and marginalized groups are particularly at risk in urban areas. In order to ensure health for all, the standards of health must consider the most vulnerable populations. This approach is often used in the setting of environmental health standards. For example, the standard for the maximum allowable levels of lead exposure is set for the most susceptible population, in this case children. This concept relates to urban planners: “To create a liveable city for all the community, one must design for its weakest members, children, disabled and the elderly. A city that is hospitable to these groups will foster a sense of well-being among all its citizens.” 10 Some Partner Cities within the BHC thematic network are also active members of the WHO Healthy Cities Group.

Cooperation between the public, private and voluntary sectors

Broader inter-sectoral cooperation in the city is vital to ensure a coordinated intervention, without one agency undermining others. This applies, for example to education authorities, health and social services in relation to equitable access, to transport authorities working with land-use authorities, to major investors in the private and voluntary sectors recognizing their social and environmental responsibilities. In a pluralist society, achieving healthy and socially inclusive cities is difficult unless businesses and public sector investors accept some shared responsibility with planning and health agencies. On the other hand, success relies on the central authorities acting transparently, being willing to pool responsibility and coordinate action. Political backing from the top tier of the city government is, therefore, an essential prerequisite for the development of long-term programmes and for effective liaison between departments in a situation in which each department tends to have its own specific remit and professional perspective. Given this co-operative framework, the critical factor that will help to ensure that planning policy is aimed towards health is absorbing health into the mainstream of plan- making and plan implementation activities. Merely tagging on a health objective or retrospectively assessing health impact is not enough.

Three Perspectives for the BHC URBACT Thematic Network

The new Health Strategy of the European Union, “ Together for Health: A Strategic Approach for the EU 2008-2013 ” (adopted on the 23 rd of October 2007) highlights, among its four main principles, the recognition of the links between health and economic prosperity and the integration of health in all policies. These principles stress the role of health in strengthening – or weakening – the development potentialities of each member State and region in Europe and call for a major effort in the co-ordination

10 Crowhurst-Lennard S.H. and Lennard H.L. (1987), “Liveable cities”, Gondolier Press, Southampton, NY.

of policies at any level, since there is a two-way bridge between the effects on health of every policy and the influence of the latter when the citizens well-being is considered. Health and health related issues can, thus, be considered to have a deep impact on the quality of life of the European citizens and this is especially true in cities, where social and environmental health determinants (such as those influencing lifestyle, the quality and quantity of available choices in terms of healthy choices, and health factors more directly linked to disease prevention, as in the case of nutrition, tobacco and alcohol) become key factors for urban policies, often without a direct legal competence of the city government in these issues. The Building Healthy Community (BHC) Thematic Network thus focuses in creating opportunities for cities to shape healthy policies for their citizens by: - sharing knowledge and competences among partner cities; - co-operating with the Regional Managing Authorities of the relevant EU Structural Funds (being the Network a Fast Track); - investing in a bottom-up approach that leaves the decision-making process in the hand of Local Support Groups, while providing the support, methodology and toolbox to design the Local Action Plans.

To achieve its goals, BHC intends to concentrate its efforts in 3 themes, each with a specific role in the 30 months lifespan of the implementation of the project. The first theme focus on Indicators and Criteria for a Healthy Sustainable Urban Development . European cities are facing new waves of transformations due to demographic change, fluxes of internal and trans-national migration, economic restructuring and changes in the traditional Welfare State structure, to name some of the most important factors of change. Experiences in tackling these issues are witnessed throughout the EU, with similarities and differences in the processes of regeneration and development undertaken but still there is a lack of knowledge in two important and interrelated fields: i. the relationship among these transformations, health and quality of life in cities and the promotion of a sustainable approach to urban development; ii. the capacity to measure this relationship, in order to monitor, assess and evaluate changes and policies that address these changes.

Health Impact Assessment (HIA) is a methodology already experimented in many EU cities and promoted by DG SANCO, and is considered as a major opportunity to integrate health into all policies. HIA can influence the decision-making process at any level, and especially the city level, by addressing all determinants of health, tackling inequities, and providing a new impetus for participation and empowerment. Some partner cities already have experience in the HIA methodology and will act as donors of knowledge and competence to all the other partners. In the same time, urban health and quality of life related indicators are also often used as an ex-ante and ex-post policy evaluation tools. These indicators, whether developed in the framework of a trans-national network or place-specific experiences and needs, can benefit from the HIA approach, since it can provide methodology and knowledge in the field of data gathering and interpretation, while, on the other hand, urban indicators that address health as related to quality of life and that aim to help to define sustainable healthy policies can provide a sound tool for improving life conditions for all citizens in EU cities.

In this framework it is of paramount importance the use of possible synergies with already existing projects and programmes that are facing the same problems and working on the same issue: this is, in specific, the case of the EURO URHIS (European System of Urban Health Indicators) project, developed under the EU Public Health Programme.

The second theme regards a Healthy Sustainable Lifestyle . As stated in the “Leipzig Charter on Sustainable European Cities” (24 th of May, 2007), «all dimensions of sustainable development should be taken into account at the same time and with the same weight. These include economic prosperity, social balance and a healthy environment. At the same time attention should be paid to cultural and health aspects» (p. 1). The holistic dimension highlighted by sustainable development in cities is reflected in the need for more sustainable lifestyles that can positively influence life conditions and promote a healthier way of living in urban areas. A positive model of sustainable lifestyle depends on health determinants, such as personal behaviour and lifestyles (including problems deriving from the abuse of tobacco, alcohol, drugs and substances, nutrition diseases, mental health, etc.), living and working conditions and access to health services, and general socio-economic, cultural and environmental conditions (taking into account, for instance, the demographic change and the ageing society or the pollution deriving from electromagnetic fields). It is a priority for European cities, then, to tackle major health determinants as it constitute a great potential for reducing the burden of disease and promoting the health of the general population.

The third theme, regarding the Use of Structural Funds in developing "Health Gains" , is a transversal one which affects all the others and will help to point each city Local Action Plan in one direction or another. This transversal theme focuses on capacity building on the use of Structural Funds in developing health gains in European cities. Health is one of the priorities identified in the “urban dimension” of cohesion policy. Several Member States have made use of Structural Funds in order to address health issues, so one of the aims of BHC is to have a focus on exchanging experience in this field. To this purpose the Fast Track label has proved to be of paramount importance to involve the relevant Managing Authorities.

II. The Partner Cities

The BHC Thematic Network started, in its Phase 1, with a five cities partnership and the idea to work around four main themes. The first five partners of the project were: Torino (Italy, lead partner), Amaroussion (Greece), Belfast (United Kingdom), Lidingö (Sweden) and Łodz (Poland). The themes that were defined in the Phase 1 of the project were: 1. Health Impact Assessment and the use of urban health indicators; 2. Policies and actions for a healthy and active ageing; 3. Use of Structural Funds in designing actions to develop “health gains”; 4. Healthy Places and Healthy Environment.

The first theme regarded the application of the HIA methodology, “a combination of procedures, methods and tools by which a policy, programme, product, or service may be judged concerning its effects on the health of the population”. The theme also referred to other urban health indicators, developed in many cities/regions as tools to assess the quality of a programme or to define an ex-ante set of actions. These indicators sometimes are not explicitly defined but can be traced in a broader set of indicators used to evaluate the quality of life in cities/regions. The second theme referred to the given the current demographic situation in many European countries, in which ageing has become an important issue in the definition of development policies at the national, regional and local level. Active and healthy ageing is, in fact, being promoted at the EU level to improve the elderly expectations in terms of quality of life and lifestyle and in terms of providing good services to prevent illness or bad health conditions. The third theme referred to Structural Funds as a way to provide an exceptional tool to design strategies to implement health and quality of life conditions in cities and regions of Europe. The fourth theme, finally, regarded healthy places and healthy environment as crucial issues in cities that has to face problems of neglected areas, physical concentration of disease and inequalities and implementation of regeneration strategies that are highly time and funds demanding. An healthy environment is also determinant in defining the degree of quality of life in a city or in part of a city. A place could be, in fact, defined as “healthy” as long as it has actually an healthy environment and it is perceived as a safe, lively, clean, nice, active area.

The definition of these themes allowed a first transnational exchange in which all the partners, started to adapt the BHC structure to the existing priorities, needs and challenges. This process included the five new members contacted during the development of Phase 1: Bac ău (Romania), Baia Mare (Romania), Barnsley (United Kingdom), Lecce (Italy), Madrid (Spain). During this phase, also taking into account the suggestions coming from the active participation in the network activities of DG SANCO and DG REGIO and taking into account the Fast Track status that brought into the network also the associated Managing Authorities, the themes have been re-elaborated and developed to better mirror priorities, needs and challenges of the extended partnership (cities, MAs and

DGs) and the definition of concrete Local Action Plans to be implemented since the Phase 2 of the life of the Thematic Network and after the end of the project itself. To this purpose the themes have been “clustered” and reorganised in order to define an effective project structure.

Fig. 1 - The ten partner cities

The first theme, on HIA and urban health indicators, have been reshaped in a wider “Indicators and Criteria for a Healthy Sustainable Urban Development”, to allow partnership with already existing projects (see previous section), to allow a direct involvement of DG SANCO and to let those cities that have already a long experience in the fields to act as donors in an transnational exchange learning process. The themes regarding the ageing population and the healthy places and healthy environment have been reshaped to allow a wider reflection of the role of health determinants in city and regional policies and of the impact of these policies on health and quality of life. The urban dimension is essential, from the point of view of the place where all policies impact and have effects and the place where integration and synergies can be effective. To this purpose the new theme has been labelled as “Healthy Sustainable Lifestyles”, because a city in which attention is not paid to this issue is a place where deep inequalities are accepted. In the case of this theme, it is foreseen – taking into account the results of the Local Mapping exercise – that cities will “cluster” themselves around a more “health determinants” oriented cluster and a more “urban regeneration” oriented one.

The third theme, “Use of Structural Funds in developing ‘Health Gains’”, is the same as in Phase 1, since it become clearer during the process that it is essential to try to use the SF with a double purpose: i. to have funds for Local Action Plans related to health and quality of life issues; ii. to establish a two-way-bridge between needs from the cities and general policies definition strategies so to let health and quality of life be considered as first class policies for the development of the EU. To this purpose, the theme will be considered as a transversal theme that will continue during the whole life of the project.

In the following pages the 10 Local Mappings are presented, in a shorter version than in the original documents but maintaining the original structure. These LMs represented a great effort for all the cities, and sometimes the already associated MAs, to share a methodology and a greater opportunity to discuss among partners of health and quality of life related issues. In the LMs it is also possible to see how health and quality of life are differently considered in the different national context and in a broader division of North-Atlantic countries, Southern Europe and Eastern Europe. Yet, it is clear that when it comes to priorities, needs and challenges the most important issue regards the citizens well-being and the definition of healthy and sustainable policies. In this case, the ten European partners showed a real shared view and a common interest. The results of this interaction are in the redefinition of the themes of the Thematic Network and in the already started process of discussion and debate at local level, thanks to the established Local Support Groups. The original documents (LMs) plus the Themes re-definition presentation that have been prepared for the Second Steering Group Meeting will be available on the URBACT website dedicated page.

Amaroussion - Greece

Christina-Anna Armeniakou City of Amaroussion - European and National Funding Οffice 10 th of September 2008

General socio-economic context: current situation and main issues related to health

Regarding the general socio-economic context of the city of Amaroussion, it is estimated that today the population of the Municipality of Amaroussion amounts to about 120.000 inhabitants and it covers a geographical area of 13.09 km2. The latest census took place in 2001 and it is repeated in every 10 years. In general, from 1991 onwards, rapid urbanization growth rates created a specific socio-economic situation where significant demographic changes took place in the city. Amaroussion attracted loads of workers (employees in the tertiary sector) and the Municipality had to invest in resolving the emerging related socioeconomic problems. For these reasons it established and utilised innovative social structures and tools (especially in social care, like Kindergartens, Third Age Protection Centres etc). The table below shows Amaroussion’s population from 2001 until today: 2001 - approximately 100.000 inhabitants 2004 – approximately 110.000 inhabitants 2007 – approximately 120.000 inhabitants and a prediction of 2010 for up to 130.000 inhabitants

POPULATION OF THE MUNICIPALITY OF AMAROUSSION

140000

130000

120000

110000

100000

90000

80000 2001 2004 2007 2010

During the last years the town develops into an increasing business centre where more than 1400 enterprises reside in Amaroussion. Despite this, Amaroussion preserves suburban features since its neighbourhoods provide the habitants with a satisfactory quality level of life with larger green field areas compared to other urban Municipalities. Moreover, the Hellenic Ministry of Health & Welfare resides in the Municipality of Amaroussion as well as 4 big private hospitals, the Olympic Sports Complex (where most of the Athens 2004 Olympic Games took place) and there are also important transit networks passing through the boundaries of the Municipality.

General indicators on the socio-economic context are presented in the following tables.

Population TOTAL Actual Population 1981-2001 Actual Population 1981 48.291 Actual Population 1991 64.092 Actual Population 2001 69.470 Change Actual Population 1981-1991 32,7% Change Actual Population 1991-2001 8,4% Actual Population 1991 - Permanent Population 2001 Actual Population 1991 64.092 Permanent Population 2001 71.551 Change Actual. 1991 / Permanent Population 2001 11,6% Distribution Permanent Population 2001 in the urban planning units 100,0% Population Density / total area of Municipality 2001 (people / Ha) 53,34 Population density/ building surface of Municipality 2001 (people / Ha) 71,07

Demographic Characteristics TOTAL Composition of the population 2001 by sex (permanent population) Proportion of males 2001 46,8% Proportion of females 2001 53,2% Composition of the population 2001 by age (both sexes-permanent population) Proportion of age group 0-14 14,7% Proportion of age group 15- 24 13,3% Proportion of age group 25-39 23,3% Proportion of age group 40-64 34,4% Proportion of age group 65+ (Indicator Ageing) 14,4% Pupil Population 2001 (permanent population) Proportion of children 6-12 years 6,7% Proportion of children 13-15 years 3,4% Proportion of children 16-18 years 3,9% Marital Status 2001 (permanent population) Proportion of unmarried (both sexes) 40,4% Proportion of married (both sexes) 48,7% Proportion of widows (both sexes) 6,5% Proportion of divorced (both sexes) 3,3% Proportion of separated (both sexes) 1,0% Population movements between 1995-2001 Proportion of household members who resided in the same Municipality in 1995 81,8% Proportion of household members who settled in the Municipality after 1995 coming from 15,5% another region of the country Proportion of household members who settled in the Municipality after 1995 coming from 2,7% another country

Household Characteristics TOTAL Households - Actual Population 1991-2001 Number of households, 1991 19.919 Members of households 1991 59.764 Number of households 2001 23.885 Members of household 2001 65.384 Change number of households 1991-2001 19,9% Average household size 1991 3,0 Average household size 2001 2,7

Households - Permanent Population 2001 Number of households 2001 24.846 Members of households 2001 68.048 Average household size 2001 2,7 Households Size - Permanent Population 2001 Proportion of households with 1 member, 2001 18,4% Proportion of households with 2 members, 2001 27,7% Proportion of households with 3-4 members, 2001 46,5% Proportion of households with 5+ members, 2001 6,6%

Educational Level TOTAL Education level 1991 (proportion in permanent population 10+ years) Permanent population 10+ years, 1991 56.237 Postgraduate degree holders (master, doctorate) 1,5% Graduates of senior colleges 15,0% Graduates of higher education 3,9% Graduates of high school/ lyceaum (6 years) 31,5% High School graduates (3 years – obligatory education) 10,7% Primary school graduates 22,5% People who have missed out on primary school but know writing and reading 6,2% People who don’t know writing and reading 2,5% Education level 2001 (proportion in permanent population 10+ years) Permanent population 10+ years, 2001 64.723 Postgraduate degree holders (master, doctorate) 3,4% Graduates of senior colleges 19,6% Graduates of higher education 12,6% Graduates of high school/ lyceaum (6 years) 32,8% High School graduates (3 years – obligatory education) 8,9% Pri mary school graduates 16,9% People who have missed out on pri mary school but know writing and reading 2,4% People who don’t know writing and reading 1,3%

Structure of economic active population TOTAL Structure of economic activity 1991-2001 Proportion of the primary sector in the economic active population 1991 0,5% Proportion of the secondary sector in the economic active population 1991 19,1% Proportion of the tertiary sector in the economic active population 1991 80,5% Proportion of the primary sector in the economically economic active population 2001 0,6% Proportion of the secondary sector in the economic active population 2001 16,4% Proportion of the tertiary sector in the economic active population 2001 83,0% Change of the economic active population in primary sector 1991-2001 78,3% Change of the economic active population in secondary sector 1991-2001 12,3% Change of the economic active population in tertiary sector 1991-2001 34,6% Analysis of economic activity 2001 in sectors (proportion of total economic active population) Α:Farming, cattle, hunting, forestry and B: fishing 0,6% C:Mines, quarries 0,1% D :Manufactoring industries 10,2% Ε :Power supply, gas supply, water supply 0,7% F : Constructions 5,3% G :Trade, repairs 15,4% Η: Ηotels, restaurants 3,2%

Ι : Transport, storage, communications 6,4% J : Intermediary financial organisations 16,9% L : Public administration, defence, mandatory social insurance 10,0% Μ : Training 8,4% Ν : Health, social care 7,9% Ο : Private households employing staff 6,0%

Profession- Position in the profession TOTAL Proportion of the economic active population 1991 who are: Employers 10,4% Employees on their own behalf 17,8% Employees 65,2% Non- wage member 1,6% Not stated profession and young people 5,1% Proportion of economically active 2001 who are: Employers 11,4% Employees on their own behalf 10,8% Employees 73,6% Non- wage member 1,1% Not stated profession and young people 3,2% Proportion of the economic active population in the groups of individual professions 2001 Higher administrative executives of the public and private sector 12,0% Persons engaged in scientific and artistic and associated professions 23,5% Technologists, technical assistants and practitioners in associated professions 13,0% Office workers and practitioners in associated professions 14,7% Employed in the services sector and vendors in shops and outdoor markets 11,5% Specialist farmers, cattle breeders, foresters, fishermen 0,8% Specialist artisans and practitioners in associated technical professions 9,1% Operators of industrial machinery in fixed industrial installations and assemblers 3,7% Unskilled workers, manual workers 4,4% Stated vaguely or poorly their professions 2,1% Not stated profession 2,0% Young people 3,2%

Employment- unemployment TOTAL Employment Economic active population (workforce) 1991 25.235 Economic active population (workforce) 2001 32.930 Percentage change in the workforce1991-2001 30,5% Total employees 1991 23.680 Total employees 2001 30.471 Percentage change in the employment 1991-2001 28,7% Unemployment Percentage of unemployment 1991 6,2% Percentage of unemployment 2001 7,5% Percentage of unempoyed young people in the overall unemployment rate of 1991 48,7% Percentage of unempoyed young people in the overall unemployment rate of 2001 43,2% Women Proportion of women in the workforce 1991 39,5% Proportion of women in the employment 1991 38,6% Proportion of women in unemployment 1991 53,9%

Proportion of women in the workforce 2001 44,7% Proportion of women in the employment 2001 44,0% Proportion of women in unemployment 2001 52,6%

Social groups 2001- Household based only on the female TOTAL Household based only on the female Number of households based only on the female in 2001 2.480 Proportion of households based only on the female in the overall households rate 10,0% (permanent 2001) Τypology of households based only on the female Proportion of households of an unmarried female 1,5% Proportion of households of a divorced female 29,8% Proportion of households of a separated female 8,5% Proportion of households of a widowed female 46,0% Proportion of households without children 32,8% Proportion of households with 1 child 44,7% Proportion of households with 2 children 19,7% Proportion of households with 3+ children 2,8% Employment of women in households based only on the female Number of women 10+ years (permanent 2001) 3.689 Proportion of economic active women 30,5% Rate of unemployeed women 7,6%

Social groups 2001- Elderly TOTAL Characteristics group of elderly (perm. 2001, 65+) Population 65+ years both sexes (permanent 2001) 10.306 Proportion of males 43,4% Proportion of married (both sexes) 58,7% Proportion of unmarried (both sexes) 5,9% Proportion of widows (both sexes) 30,9% Proportion of divorced (both sexes) 3,2% Proportion of economical active 65+ 6,3% Proportion of employees 65+ 100,0% Households of elderly Household with at least a member of 65+ years 7.206 Proportion of households with at least a member of 65+ years 29,0% One- person households with a member of 65+ years 1.613 Proportion of one- person households with a member of 65+ years 6,5% Two- persons households both of member of 65+ years 1.390 Proportion of two- persons' households both of members of 65+ years in total 5,6%

Social groups 2001- Economic immigrants TOTAL Features of the group of foreigners Foreigner- total 2001 (legal population) 4.053 Proportion of foreigners in the whole population 2001 5,7% Proportion of E.U. nationals 12,1% Proportion of countries outside the E.U. 87,9% Percentage of those who stated that they have settled for work 42,9% Proportion of males 46,8% Proportion of age group 0-14 17,9% Proportion of age group 15-24 17,3% Proportion of age group 25-39 32,9%

Proportion of age group 40-64 27,0% Proportion of age group 65+ 4,9% Employment of foreigners (2001) Proportion of econ. active in the overall foreigner rate 10+ years in 2001 60,2% Percentage of unemployed 2002 7,2% Proportion of economic active foreigners in sectors, 2001 Α:Farming, stockbreeding, hunting, forestry & B: fishing 1,5% C :Mines, quarries 0,0% D :Manufacturing industries 8,6% Ε :Power supply, gas supply, water supply 0,2% F : Constructions 18,1% G, Η :Trade, repairs, hotels, restaurants 15,8% I :Transport, storage, communications 3,5% J : Intermediary financial organizations 1,6% Κ-P : Other services 41,1% Vaguely stated or not stated sector economic activity 6,6%

Theme 1: Health Impact Assessment (HIA) and the use of urban health indicators

The Municipality of Amaroussion has no concrete experience in HIA. A couple of years ago (in 2004 until 2006), the Municipality of Amaroussion established a Municipal Urban Observatory website aiming at providing a methodological and administrational tool for evaluating the impacts of the policies implemented by the administration of the Municipality. The main activity of this Observatory is the collection, registration, elaboration and provision of information related to socio-economic and environmental indicators which are based on the following 6 main axes: demography, everyday life, environment, economic growth, social cohesion and culture. The final outcome of this Urban Observatory is an Integrated Information System which disseminates the available statistical information through a dynamic web-portal to be used by the citizens, the stakeholders and the municipal staff for meeting their needs. Nowadays, also in continuation with the Municipal Urban Observatory which will be further developed, the Municipality of Amaroussion has implemented the Habitat Agenda and within this context it has developed a ‘Complete Local Plan of Action for Human Settlements in its geographic area’ in cooperation with a few other neighboring cities. The Habitat Agenda is a Global Plan of Action for Human Settlements which aims at stressing all the various parameters that need to be taken into account in order to ensure that the growth of cities and settlements respects the safe, healthy and isonomic way of living of the inhabitants as well as the sufficient and satisfying housing for everyone within a sustainable residential environment. Thus, within the Habitat Agenda, Amaroussion’s Local Plan of Action includes environmental targets, grouping of targets, concrete actions to be taken, performance indicators and monitoring of the whole process of potential improvement and enhancement.

Indicatively, for each of the 6 main axes mentioned above a set of specific indicators correspond to the chosen axes (please see the table below):

DEMOGRA EVERYDAY ENVIRONME ECONOMIC SOCIAL CULTURE PHY LIFE NT GROWTH COHESION Population Hospital beds Structural factor Change in the Poor people Educational level per 1000 stock of buildings inhabitants and houses from 1991-2001 Age Medical Analysis of Construction Immigrants Municipal libraries

distribution doctors per common/ characteristics 1000 beneficial to the inhabitants public places Household Educational Use of land Cost of the land Equal Museums distribution infrastructure and of housing opportunities Kindergarten Scheduled Unemployment Internet infrastructure building Infrastructures Accessibility to Structural of Telecommunication for the elderly common/ financial activity s beneficial to the public places and to public buildings Sports Low speed Mass and facilities traffic Communication media Levels of Average income emissions air of the city’s pollutants households Generation and collection of waste Management of waste Urban green fields

From the indicators set out above, a set of urban health indicators mainly oriented towards the quality of life in urban areas have been selected for the purposes of this local mapping exercise which are the following: Axis of ‘Environment’: o Levels of emissions of air pollutants : this indicator measures the emission of the following air pollutants – CO, NO, NO2, O3, SO2 – in the area of Amaroussion o Generation and collection of waste : this indicator refers to the production and collection of solid waste (in tons)from the area of Amaroussion o Management of waste : this indicator refers to the ratio of solid waste produced per inhabitant and to the average ratio of recycled waste per inhabitant o Urban green fields : this indicator refers to the green urban areas and to the ratio of urban green spaces per inhabitant Axis of ‘Everyday life’: o Infrastructures for the elderly : This indicator refers to the infrastructures supporting the elderly and in particular to the number of the Centers for the Open Protection of the Elderly, to the staff dedicated to this purpose, to the registered members per year and to the average number of the elderly/ members per Center.

Nonetheless, from the indicators set out above, a set of urban health indicators mainly referring to a medical approach to health have been selected for the purposes of this local mapping exercise which are the following: Axis of ‘Everyday life’: o Hospital beds per 1000 inhabitants : this indicator refers to the total number hospital beds of both public and private hospitals that function within the boundaries of the city and their ratio per 1000 inhabitants o Medical doctors per 1000 inhabitants : this indicator refers to the total number of medical doctors working for public hospitals and their ratio per 1000 inhabitants

Epigrammatically, the expectations of the Municipality of Amaroussion from participating in the ‘Building Healthy Communities network’ and in particular from implementing the Health

Impact Assessment (HIA) and a set of Urban Health Indicators may be summarised in the following: – To develop a coherent and responsive local strategy for urban and sustainable development – To gain experiences from other European cities, to exchange information and experiences and to create administrative conditions for the implementation of ‘healthy’ cities’ strategies in our Municipality/ country – To place the issue of health even further up on the social and political agenda of our Municipality – To practically familiarise the relevant health actors with HIA & with the establishment of urban health indicators : a great potential especially through the intermunicipal network of health structures – Active ageing : to actively involve and interconnect all the relevant actors – Healthy places, healthy environments : to promote the interaction of the relevant departments of the Municipality and to set concrete grounds towards this direction

In particular, as it has been already mentioned the Municipality of Amaroussion has no concrete experience on HIA. Therefore, it was decided to use the relevant available data on the World Health Organisation’s (WHO) website in order to foresee and define the great potential of applying the HIA.

Theme 2: Policies and actions for an active and healthy ageing

The Municipality of Amaroussion is a group of legal entities whose operations aim at the improvement of the citizens’ life. The actions undertaken to meet needs in relation to the theme at stake are provided below for each relevant legal entity:

The Intermunicipal Health and Welfare Network: It is worthwhile mentioning that the Municipality of Amaroussion, introduced the initiative of establishing an Intermunicipal Health Network. The network is mainly structured by Neighbouring Municipalities which share common concerns. The main goal of the Network is the enhancement of improved Health Care Services. Additionally, the Intermunicipal Network would create a framework of cooperation among the Municipalities and the corresponding Ministries in Greece. Overall, the main purposes of such a concrete action can be summarised as follows: ♦ Developing actions along with other Local Administrative actors in the health sector (i.e health and employee’s insurance, Corporate Social Responsibility Programmes etc.) ♦ Pursuit of a formal membership in European policy-making bodies and planning related to issues of medical and social welfare ♦ Planning and implementation of common programmes with non-governmental organisations related to the health and social welfare sectors in Greece and abroad ♦ Cooperation with scientific actors (both public and private) related to health and social welfare for the realization of common Intermunicipal needs. ♦ Raising awareness through actively pparticipating in voluntary programmes such as “Protect Oneself and Others” which was organized by various Hellenic Ministries in order to educate adults on how to manage crises (i.e earthquake, fires etc) ♦ Educational seminars and events available to the citizens and employees related to the Health sector

Municipal Enterprise of the provision of social services :

The Municipal Enterprise of the provision of social services of the Municipality of Amaroussion was established in 1984, aiming at the following: ♦ Implementation of programs for protecting the elderly out-of-institutions ♦ Implementation of projects of psychosocial support and provision of services of preventive health

In particular, the Municipal Enterprise coordinates the following:

♦ A Centre of Psychosocial Support aiming at: o The application of interventions which promote the mental health of the residents of the city (first degree health care). Advisory support (in groups, individual) o Diagnostics - Psychological evaluation o Informative events, speeches etc

♦ A Municipal Polyclinic providing the following: o Medical support to the citizens with the support of volunteer medical doctors o Provision of psychological support to the elderly o Social events

Organization of Environment, Land Planning and Quality of Life ♦ Coordination and planning of all municipal activities related to the enhancement of the natural and urban environment ♦ Monitoring of the quality of air and of the drinking water of the city ♦ Monitoring of environmental activities of other cities (both at national and European level) ♦ Organization of environmental events and sensitization of the citizens ♦ Provision of information to the citizens on environmental issues ♦ Research on products friendly to the environment ♦ EMAS registration

Centre for the Open Protection of the Elderly ♦ The practical/ actual support of the elderly though programs that aim at their activation ♦ The provision of services for the prevention of biological, psychological and social problems of the elderly so as to remain autonomous and active within society ♦ The sensitization and the cooperation with the wider society and relevant stakeholders in relation to problems and needs of the elderly ♦ Provision of in-house physiotherapists when needed ♦ Programs of preventive medicine on a daily basis

Health Organization: ♦ Provision of services on preventive healthcare with the active and substantial support of local physicians on a voluntary basis ♦ Conduct and implementation of programmes on health prevention (ex. Inoculation of kindergarten personnel, allergy screening, screening of cholesterol levels of the citizens, blood donation) ♦ Contribution to the prevention of accidents (ex. Seminars on trauma-life support, provision of first aid) ♦ Organization of informative events for citizens on a healthy way of living

Welfare and Civil Protection Organization : Campaigns on a healthy way of living (ex. Campaign against smoking) through several events and leaflets

Municipal Enterprise of Sports: The Municipal Enterprise of Sports of the Municipality of Amaroussion was established in 1999. The scope of this enterprise is to provide sports installations in order to support sports activities and suitable infrastructures where all citizens will be able to spend in a creative and healthy way their free time. Min specific, there are a number of events that have been implemented, such as “Exercising for All” for all ages, in about 50 sports spaces all over Amaroussion.

Municipal Enterprise of Culture: The scope of this enterprise is to provide services to the citizens aiming at their entertainment and intellectual cultivation. More concretely, there are special adult workshops which make older people fulfill their day in a pleasant and creative way by remaining active members of the society.

Priority, needs, challenges

The Municipality of Amaroussion has to be further modernized in order to be able to respond to the needs of its citizens due to the constant increase in the number of its residents, to the number of employees working within the city’s boundaries, to the hospitals that are based in the city and provide services to hundreds of people everyday as well due to the large number of vehicles and people/ visitors passing through the municipality’s main road arteries.

Therefore, the basic development scheme must be composed of specific measures and actions that will deal with the overall benefit of the city and its inhabitants. The challenge for the Municipality would be the definition of the required conditions in order to connect its metropolitan character with its suburban profile which is accompanied by a high quality of life for its citizens. These actions should include the following:

♦ appropriate traffic arrangements, ♦ appropriate parking arrangements under the city, ♦ adjustments for environmental protection and development of green spaces, ♦ support actions, acting as a rival pole of supralocal operation, for maintaining the suburban character of the city

♦ development actions, for the economic growth of the region, for reducing unemployment rates, for reinforcing the commercial activities ♦ development and implementation of qualitative services with the use of innovation as a basic tool for the improvement of effectiveness in the service of the citizen ♦ Improvement of the environmental picture of city, measures for the protection of the environment, new energy standard, better quality of life ♦ Improvement of all indicators of prosperity and social protection and solidarity

Theme 3: Healthy Places and Healthy Environment

The wider region of the Municipality of Amaroussion is characterised by powerful tendencies of urban space reformation at metropolitan level. Nowadays, Amaroussion is threatened by an environmental falloff which steps from the wider changes in the metropolitan urban space and it is expressed with intense ‘cracks’ and differentiations in the regions and functions of city. The presence of disparate uses, which however occupies big areas of land (eg the Olympic Sport

Complex), worsens these imbalances. The ‘cracks’ that are caused by the road axes which physically split the city and prevent communication to a certain extent as well as the discontinuities that stem from the internal differentiations cut up the city at social level. The social and cultural dimension of inequalities is expressed by the cutting off of certain social groups that live in degraded neighbourhoods (eg Working Residences).

The structural discontinuities have also obvious consequences for the urban landscape reflecting also the ‘cracks’ at the cultural level. The new ‘architecture’ perverts the built-up history of the place, and the natural landscape and traditional buildings are gradually corroded and destroyed. Nonetheless, the presence of all sorts of signaling (eg advertisements) also constitutes an incoherent competition which downgrades the city even more. The big number of transportations caused by the new uses burdens the traffic and parking of vehicles, complicating further the traffic congestion and placing at risk the safety of the pedestrians.

The main problems that can be identified epigrammatically are the following: ♦ Air pollution-high concentrations of ozone and particles (10 m) due to the high circulation of vehicles and some large roads-avenues ♦ Intense construction activities especially in specific urban unities ♦ Small number of parking places and a lot of traffic problems ♦ High levels of sound due to the construction activities and circulation of vehicles ♦ Aesthetic pollution due to advertising signs and ugly building appearance ♦ Low percentage of green places in proportion with the population ♦ Low quality of pavements in particular areas of the city ♦ Lack of drainage systems and pipes of pluvial water in some areas of the city ♦ Lack of security ♦ Lack of cleaning activities in public spaces

Therefore, taking into consideration all the above the following needs may be acknowledged : ♦ Need for more green places that will improve local air quality ♦ Pavements refurbishment or construction of new ones ♦ Circulation changes and new efficient regulation circulation ♦ Implementation of facilities for people with special needs e.g pavements ♦ Formation of streets and other public places ♦ Completion of drainage construction works Citizens’ continuous information about the recycling system because of several emerged problems

Actions/projects that tackle this issue: ♦ Implementation of municipal and inter-municipal transportation which offers a good solution to the traffic problem, to the improvement of life quality (low CO 2 emissions), health protection, and energy saving. ♦ Implementation of projects that concern the extension of already applicated recycling systems for the improvement of life quality and health protection (prevent the pollution of aquatic and terrestrial systems) ♦ Implementation of projects that lead to a “greener” city such as: designing projects for planting, designing projects for green paths, reformation of playgrounds ♦ Implementation of energy efficiency projects in order to improve the air quality: Participation in European and national funded projects about energy efficiency ♦ Functioning of a special corps conducting intensive patrol to ensure the security of citizens Awareness raising actions related to environmental issues: coordinated cleaning activities of parks

The general impression that Amaroussion is one of the less downgraded regions of Attica nowadays refers to few particular parts of the city, mainly the ones around the city centre which are westward from the Kifissias Avenue (the main avenue which connects the city centre with the northern suburbs of Attica). The city faces dangers of degeneration of its urban space which are however more obvious in socially and economically isolated neighbourhoods. Such a characteristic case is the entitled ‘Urban Unit 7’ and in particular the part where the Working Residences are located.

This particular ‘Urban Unit 7’, the so-called ''Working Residences'' district, covers an area of about 600 acres and it is encompassed by main road arteries such as the avenues of Kifissias and Attica. Nonetheless, within the boundaries of this urban Unit there are a number of municipal buildings intended for faculties of higher education, a high-school building, a lyceum, a local hotel, the Municipal Summery Cinema, two chapels characterized as monuments and a Holy Temple. Moreover, a new train station has been functioning from the Olympic Games 2004 onwards constituting a nodal point in the transportation infrastructure. In the centre of this area there are the Working residences which are relatively large groups of flats of flats. Nevertheless, the area is crossed by a stream which is unfortunately considered being a threatened biotope. In addition, the unevenness of the region is another unfortunate characteristic, which instead of functioning in favour of the sustainable growth of the city due to the element of diversity, on the contrary, it creates conflicts against the ‘weakest’ users such as the capacity of housing which encourage the presence of imbalances.

The enormous traffic problem accompanied by harmful effects which are mainly caused by the big road arteries that encompass the urban unit, overload the natural environmental parameters and isolate this part of the city from the break away from the rest of the city. The way of living becomes incompatible with the required quality of life of the citizens and qualitative elements such as the natural landscape and the monuments are subjected to debasement due to the incontrollable growth of the area.

Even nowadays, a big part of the region is not well-built or structured, the town-planning is not finished while the actions planned to be implemented are still in progress. More specifically the Working Residences have the following concrete problems: ♦ Social exclusion from the rest of the city ♦ Degraded buildings and destroyed environment of the communal spaces ♦ Serious traffic problems accompanied by obvious harms (ex. air and noise pollution) ♦ The buildings are old and have suffered damages from the big earthquake of 1999

The residents who are mainly old-aged people face serious problems with their way of living as the frames of their doors and windows do not cover the basic requirements in insulation. This results in people getting more and more ill during winter. Nevertheless, the residents are highly insecure due to criminal incidents such as burglaries and attacks.

In this Urban Unit there is no network of pluvial and dingily sewerage. Very often, at least once a month, residents complain about blocked manholes whose sewages end up in the courtyards of the houses.

For the compilation of all those essential elements that concern the demographic characteristics and the social needs of this selected area, a survey was conducted by distributing a questionnaire in the residents of the entire region. With respect to the results of the questionnaire, these are as follows: ♦ 36% declared the lack of green spaces

♦ 46,6% pointed out the problem with the cleanness ♦ 44,7% pointed out the lack pf parking spots ♦ 29,3% pointed out the presence of arbitrary constructions ♦ 26,1% pointed out the faulty streets ♦ 42,9% mentioned the lack of the sewerage network 73,3% reported other problems such as the lack of lighting, lack of policing and safety, traffic problems, lack of traffic lights, noise pollution, as well as more specific problems of such as the lack of elevator in certain blocks of the Working Residences where aged people reside facing kinetic or other heath problems

Theme 4: Use of Structural Funds in designing actions to develop "health gains"

Regarding the situation of the two European Structural Funds – the European Social Fund (ESF) and the European Regional Development Fund (ERDF)– in our region the following two operational programmes are mostly related to health and quality of life actions:

1. Operational Programme ENVIRONMENT In the context of the 3 rd Community Framework Programme (2000-2006) there are still some actions running that have been granted extension due to special conditions. Originally, the approval date was 21/07/2001 and by 15.06.2008 the funds were only partially absorbed (71%). Therefore, under special circumstances most axes of the programme were extended up to 31/12/2009 except from the 1 st axis (Special interventions in the field of draining – Actions for reserving water resources). It should be thus noted that there are no open calls for proposals.

In the framework of the National Strategic Reference Framework (NSRF) which establishes the main priorities for spending the EU Structural Funds between 2007 and 2013 for Greece, the Operational Programme “Environment and Sustainable Development” has been approved with the decision Ε(2007)5442/5.11.2007 of the European Commission for providing financial support to the regions of Greece from the Regional Development Fund (ERDF) in the context of the convergence target and of the Cohesion Fund (CCI 2007 GR 16 PO 005).

Some of the main actions that will be implemented in the context of this particular Operational Programme (OP) are the following: total management of solid and dangerous waste and protection of the soil, management of urban waste, implementation of action plans for eliminating air – sea - coast pollution, flood-preventing infrastructures, prevention and efficient confrontation of physical and technological disasters.

In particular the total budget of this OP is 2.250.000.000 EUROS (1.800.000.000 EUROS Community funding and 450.000.000 EUROS national funding. It is estimated that supplementary to this amount, 519.000.000 EUROS will be unloaded from national resources to cover expenses of projects that are not co-funded by the European Union, such as as expropriations.

1. Formulation of the strategic, general objectives and priority axes of the OP The Strategic Objective for the Sector of Environment and of Sustainable Development for the programming period 2007 - 2013 is the following: The protection, Upgrade and Sustainable Management of the Environment, so that it constitutes the base for the protection of public health, the rise of quality of life of citizens as well as the basic factor for the improvement of the competitiveness of the economy.

The strategy of the Program, mainly, focuses in the effort of incorporating the Community Directives with regard to the urban sewages and the urban solid waste with the application of the Directive 60/2000, the promotion of the green transports and the construction of flood- preventing infrastructures and infrastructures of water supply.

The strategy of Program is structured around seven basic strategic priorities/ choices: 1) Protection of the Atmospheric Environment - Support of “Green” Transports - Confrontation of Climatic Change - Renewable Sources of Energy (Priority Axes 1 and 6) 2) Protection and management of watery resources. (Priority Axes 2 and 7) 3) Prevention, confrontation and management of environmental dangers (Priority Axes 3 and 8) 4) Protection of territorial systems and management of solid waste. (Priority Axis 4) 5) Protection of Nature and Biodiversity. (Priority Axis 9) 6) Development of Institutions and Mechanisms for the effective exercise of environmental policy and sensitization of citizens. (Priority Axis 10) 7) Technical support (Priority Axes of 5 and 11)

Analytically the general objectives that are formulated are:

GENERAL OBJECTIVE 1 The Sustainable Management of environmental means, natural reserve and Urban Centres

GENERAL OBJECTIVE 2 The improvement of effectiveness of Public Administrations in the planning and the application environmental policies and the improvement of response of Society and Citizens on the issues Environmental Protection

2. Priority Axes of concise content, main projects/actions For the achievement of the general objectives of the present Operational Program, there are distinguishable sectors of intervention, that are operationally organized in two Groups of Priority Axes (A and B), for each one of the Community Funds that finance the OP, the Cohesion Fund and the ERDF respectively. The axes are shaped in such a way, so as to include actions that contribute in the achievement of the general objectives.

Therefore, the Priority Axes are the following (please note that for each Priority Axis specific objectives have been defined):

PRIORITY AXES of GROUP A – FUNDING by the Cohesion Fund A1. Protection of Atmospheric Environment and Urban Transports - Confrontation of Climatic Change - Renewable Sources of Energy A2. Protection and Management of Watery Resources A3. Prevention and Confrontation of Environmental Danger A4. Protection of Territorial Systems - Management of Solid Waste

PRIORITY AXES OF GROUP B – FUNDING by the ERDF B1. Protection of Atmospheric Environment - Confrontation of Climatic Change B2. Protection and Management of Watery Resources B3. Prevention and Confrontation of Environmental Danger B4. Protection of Natural Environment and Biodiversity B5. Institutions and Mechanisms

2. Operational Programme HEALTH AND SOCIAL WELFARE In the context of the 3 rd Community Framework Programme (2000-2006) there are still some actions running that have been granted extension due to special conditions. Originally, the approval date was 04/04/2001 and by 15.06.2008 the funds were only partially absorbed (72%). Therefore, under special circumstances the 2 nd axis entitled “Mental Health” was extended up to 31/12/2009.

In the framework of the National Strategic Reference Framework (NSRF), a National Strategic Plan for health and Social Solidarity has been drawn up which will be financed by the approved Sectoral and Regional programs of the NSRF.

The main priorities/ axes that have been approved form the European Union to be implemented in our region and consequently in the Municipality of Amaroussion directly or indirectly linked to health and quality of life are listed below:

Operational Programme ENVIRONMENT 2000 -2006 ♦ Axis 1: Watery Environment ♦ Axis 2: Solid Waste ♦ Axis 3: Civil Protection, Protection of Landscapes and Marine Environment ♦ Axis 4: Atmospheric Environment - Noise ♦ Axis 5: Institutions, Environmental Sensitization ♦ Axis 6: Other Environmental Actions ♦ Axis 7: Land use - Urban planning - Reformations ♦ Axis 8: Management of Protected Regions and Biotopes ♦ Axis 9: Environmental Actions with the attendance of the Private Sector (compatible with the Community legislation) ♦ Axis 10: Technical Support

Operational Programme HEALTH AND SOCIAL WELFARE ♦ Priority Axis 1 : “Health” Improvement of quality and effectiveness of the National Health System in the sectors of first degree health care, of hospital care and of public health ♦ Priority Axis 2: “Mental Health” Axis 2 had as basic aim to promote the reformation of the sector of Mental Health. The strategy and the objectives of this Axis are supported by a concrete National Policy, which is expressed in the NSRF for the Psychiatric Reform 2000- 2010 (Program PSYCHARGOS B'). ♦ Priority Axis 3: “Welfare” ,this Axis focuses on two fundamental operational objectives: o Provision of new first degree health care services at local level to individuals that are excluded or threatened from social exclusion and more generally to sensitive population groups, in the direction of supportive policies that aim at the guarantee of equal opportunities and at the promotion of employment. o Promotion in the autonomous way of living and social-economic rehabilitation of individuals who live in closed type institutions ♦ Priority Axis 4: “Human Resources” The further growth and qualitative improvement of competences and knowledge, mainly of the employees and secondarily of the unemployed, of the health and social care sectors.

In specific, the projects listed below (either already implements or ongoing) are co-funded by structural funds and are directly or indirectly linked to health and quality of life: ♦ Complete programme of sustainable development for implementing the Habitat Agenda (study onHabitat). ♦ Integration of the network of pedestrian zones and low-speed roads and of open spaces – controlling and securing of transportations – upgrading of neighbourhoods.

♦ Regeneration of building blocksof the working residences of Urban Unit 7 ♦ Functioning of a support in-house unit ♦ Unit of social welfare ♦ Programme ‘New Perspective’ ♦ Office for providing socail supportive services Participation in the Action Plan of the NGO ‘Centre pf Research and Action for Peace’ entitled « Excluding the social exclusion »

Indicative projects related to health and quality of life: – TOWN TWINNING: Thematic Conference: European local authorities explore ways and cooperate towards the improvement of citizen everyday life – TOWN TWINNING: Thematic Conference: Exchange best practices on urban environment – LIFE: Integration and Development of Environmental Management Systems – LIFE : Local Authority EMAS and Procurement – LIFE: Local Agenda 21 – LIFE: Local Authority and Business: Promoting Voluntary Environmental Agreements – LIFE: Green Games & Local Authorities – LIFE: European ecoBudget pilot project for local authorities steering to local sustainability – 5th Framework Programme : Zero Emission Neighbourhoods – THERMIE : Zero Emission vehicles in Urban Society – THERMIE: Formulation of a strategic plan for the reduction of CO2 emission

Indicative actions - needs that will be implemented during the 4 th programmatic period are the following: ♦ Preventive policies with regard to the deterioration of living conditions in the urban space because due to the increased demographic concentration ♦ Support of health structures giving emphasis on the first degree sanitary care ♦ Creation of infrastructures for the secure concentration, transportation and final disposal contagious and radioactive hospital waste (solid and liquid) ♦ Operation of structures of the National System (Centre), Information Health Center, eHealth Competence Centre ♦ Actions of protection of public health ♦ Support of the National Organization of Transplantations ♦ Blood Management ♦ Protection of the medical data of the Knowledge Society ♦ Introduction of health cards and health cards for professionals ♦ Actions for the completion of infrastructures of informative systems for the improvement of reciprocity of the sanitary system ♦ Development of the national system of tele-medicine ♦ Actions for the organization and operation of social solidarity and institutions of health ♦ Energy rationalization of the health units ♦ Networks of distribution of natural gas, electricity and heat in big hospital units Support and development of centers of health tourism and full recovery

Sources ♦ Activity Review document of the Municipality of Amaroussion for the year 2007, 2008 ♦ Activity Review document of the Municipal Enterprises/ Companies of the Municipality of Amaroussion for the year 2007, 2008 ♦ Hellenic National Strategic Reference Framework document ♦ Operational Programme of the Municipality of Amaroussion, 2008-09-10

♦ Community Framework Programme 2000-2006 – Operational Programme “HEALTH & WELFARE”, Special Management Department/ Unit A’, Presentation from technical visit, 25 October 2007, Anna Kananaki ♦ Community Framework Programme 2000-2006 – Operational Programme “HEALTH & WELFARE”, Special Management Department/ Unit A’, Presentation on the allocation of development actions in the field of health and social welfare in the sectoral operational programmes of the 4 th programming period, Athanasia Gerostathou ♦ Study on the Integrated Local Programme of Sustainable Development in applying the HABITAT AGENDA, 2007 ♦ URBAN OBSERVATORY OF AMAROUSSION website: www.maroussi-observatory.gr ♦ WORLD HEALTH ORGANISATION website: www.who.int/hia/about/why/en/index1.html ♦ Documents and information from the Municipal Office of Urban Planning, Environment and Quality of Life ♦ Documents and information from the Municipal European and National Funding Office ♦ Articles of Association of the Municipal Health Organisation ♦ Articles of Association of the Municipal Welfare and Civil Protection Organisation

Bacău - Romania

Corneliu Pricope Bac ău Municipality - Bac ău Local Development Agency 24 th of July 2008

General socio-economic context: current situation and main issues related to health

The city of Bacau has a surface of 43, 2 km², being the largest city from the county. It is situated 9km away North-East from the intersection of two rivers, Siret and Bistri Ńa, being one of the biggest and most important cities from Moldova. Also, Bacau city is situated at the intersection of terrestrial and airway communication ways. The road and railroad network of national and European interest cross the city from North- South and East-West. Bacau is crossed from North to South by the European road E85 (DN2 that is part of the Pan European Corridor No. IX) and links Bucharest with the North side of the country, being at the same time the main corridor that crosses Moldova towards Greece, Bulgaria, Ukraine and Russia. In the territorial systematization plan of Romania, regarding the road system, the high way Bucharest – Suceava – Ukraine will also cross through Bacau city. In the same project it is included the high way Tg. Mures – Piatra Neamt – Roman – Iasi. If we take into consideration the construction in the following period of the two roads that will go around Bacau and Roman, it is forecasted that the distance between Bacau and the high way Tg. Mures – Iasi will be around 20 or 25 km. The city of Bacau will also have access towards the high way that links the South to the North of the country, as well as the one from West to East. The national road DN 2F links Bacau with the city of Vaslui towards the East, and towards the West Bacau communicates through the national road DN 11 (E577) with the city of Brasov. This way it is made the connection with the corridors towards Hungary, Austria, Germany, Italy, France, Spain. DN 15 links Bacau with Piatra Neamt and with the areas of tourist interest, and the connection between Bacau and Moinesti and Comanesti is made by the national road DN 2G. The airway connection with the capital of the country and with the exterior is offered by Bacau International Airport that also has a centre for directing international flights that open the ways towards the entire world. The city of Bacau is an important railway node, with modern infrastructure for the person and merchandize transport. The investments for accomplishing the objective Euro Station Bacau are in development. The evolution of the legal and stable population from the Bacau Municipality at the 1st of June and their distribution on gender, is as in fig. 1, while in fig. 2 there is a profile of the population and the main demographical phenomena.

Fig. 1

2000 2001 2002 2003 2004 2005 2006 Bacau 208,487 208,047 184,562 183,211 181,528 180,318 179,662 The total weight in the Bacau Municipality (%) Bacau 27.5 27.4 25.3 25.2 25.0 24.9 24.8 Comparing with the last year, the dynamic of the stable population at the 1st of July Bacau 99.8 88.7 99.3 99.1 99.3 99.6 Comparing to the year 2000, the dynamic of the stable population at the 1st of July Bacau 99.8 88.5 87.9 87.1 86.5 86.2

Fig. 2

2000 2001 2002 2003 2004 2005 2006 Municipality 207,573 206,765 184,542 183,484 181,144 180,516 179,507 Male 100,843 100,376 89,442 88,624 87,278 86,812 86,276 Female 106,730 106,389 95,100 94,860 93,866 93,704 93,231 The gender structure of the stable population on the 1st of July (%) Municipality 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Male 48.6 48.5 48.5 48.3 48.2 48.1 48.1 Female 51.4 51.5 51.5 51.7 51.8 51.9 51.9 The total weight in the Bacau Municipality (%) Bacau 27.6 27.4 25.4 25.3 25.1 24.9 24.9 Male 27.0 26.8 24.8 24.6 24.3 24.2 24.1 Female 28.2 28.0 26.0 26.0 25.8 25.7 25.6 Comparing to the last year, the dynamic of the stable population at the 1st of July (the last year = 100%) Municipality 99.6 89.3 99.4 98.7 99.7 99.4 Male 99.5 89.1 99.1 98.5 99.5 99.4 Female 99.7 89.4 99.7 99.0 99.8 99.5 Comparing to the year 2000, the dynamic of the stable population at the 1st of July, on (the year 2000 = 100%) Municipality 99.6 88.9 88.4 87.3 87.0 86.5 Male 99.5 88.7 87.9 86.5 86.1 85.6 Female 99.7 89.1 88.9 87.9 87.8 87.4

Between 2000 – 2006, the population of the Bac ău Municipality diminished, and the stable population was with 13,5% lesser than in 2000. In these terms, in the Bacau Municipality, in the last years, are concentrated almost 25% from the total population of the district. In 2000 – 2005, the average number of the salaried persons diminished in the Bacau Municipality (in 2005, comparing to 2000, the average number of the salaried persons was with 17,7% smaller) and in the district too. Despite that, the total avoirdupois weight of the salaried persons remains constant. The Bacau Municipality has 1388 unemployed workers, of which 815 females and 573 males, calculated after a sample of stable population between 18 and 62. The unemployment rate in April 2008 was of 2, 1% from the total stable population, of which 1, 2 % females and 0,9% males. This was calculated as a proportion between the number of unemployed workers and the stable population of the Bacau Municipality, with the age between 18 and 62. Calculated in this manner, the unemployment rate is undersized.

Fig. 3 The average number of the workers (number of persons)

2000 2001 2002 2003 2004 2005

Bacau Municipality 70,165 67,799 63,768 65,020 57,947 57,773 The total weight in the Bacau Municipality (%) Bacau Municipality 50.7 48.2 47.6 49.3 47.4 48.1 Comparing to the anterior year, the dynamic of the workers average number (anterior year = 100%) Bacau Municipality 96.6 94.1 102.0 89.1 99.7 Comparing to the year 2000, the dynamic of the workers average number (year 2000 = 100%) Bacau Municipality 96.6 90.9 92.7 82.6 82.3

The Inter-community Development Association “The metropolitan Area of Bac ău” established itself as association, on the basis of a voluntarily partnership, between the Local Council of Bac ău and the locals councils of the villages situated on distances over 30 km and the County Council of Bac ău. Through this association it was created the opportunity of a durable development of the area after o coherent strategy. With the implication of the local communities, it was created the investment opportunities in infrastructure and tourism, and for the SMEs development. We also estimate an expansion of field offer for the investors.

Some dates The name of the city/village/ Number of Total administrative territorial No inhabitants at Surface unit 1 of July 2006 (ha.) 1. Bac ău 179.507 4.318 2. Bere ti-Bistri Ńa 2.110 3800 3. Buhoci 4.994 5151 4. Faraoani 5.588 3.889 5. Filipesti 4.728 6908 6. Gioseni 3.506 1276 7. Hemeius 4.266 2.792 8. Itesti 1.441 4000 9. Letea-Veche 5.459 4.249 10. Luizi-Calugara 5.366 3.165 11. Măgura 4.401 1355 12. Mărgineni 8.940 8.348 13. Pr ăje ti 2.557 2180 14. Sărata 2.224 2.480 15. Săuce ti 4.655 5.230 16. Tama i 3.241 1769 17. Traian 2.976 3580 18. Secuieni 2.089 5032 19. Odobe ti 2.445 4560 20. Izvorul Berheciului 1717 5713 21. Garleni 6727 3593,7 22. Blagesti 7290 9630

Strong items: Facilitates the investors’ access to the necessary fields for the business development; Favourable conditions for the durable development of the area; Derived economical benefits from the attractiveness growing of the area for the investors; Transport infrastructure improvement and development; Facilitates the complete arrangement of the territory at regional level; Diminishes the imbalances created between the centre and the suburbs, caused by the dispersal in the plan of demographical, social and economical structure, by the imbalances from the common transport, infrastructure financing, spaces for habitation and services; Economical competitiveness growth of towns from the metropolitan area comparing with the neighbouring regions; Improvement of environment conditions; Resolving the town overflow, of town agglomeration; Completion of habitation demands, and of fields for the residentiary areas; More budgetary funds for towns with small incomes;

Jobs creation by attracting the investors; Growth of standards of living, of PIB/inhabitant; Regional development through investments in social, health, affairs, transport and environment infrastructure; Networks expansion and modernization of public utilities; Access to structural instruments for the local communities; Bac ău County is one of the most important poles of economical development in the Nord-East Region 1; Strategic and geographical position (for investments and for economical and commercial activities) of Bac ău City, situated in the centre of Moldavia, at the confluence of some important roads, railways and airlines; Existence of 2 universities centres, one of state and the other private; Existence of research-innovation centres, in university environment but also in different economical sections, with private participation and initiative.

The bold elements in the list above and also in the list below represent objectives of interest for our project.

Objectives

1 The integrated management of rags – the ecological depository of wastes for the Bac ău City and its regions. 2 Bac ău Centre of Business and Exhibitions 3 The complete development of a neighbourhood from Bac ău 4 Rehabilitation, modernization and equipments endowment of the Social Centre for the Old People, from No.2 Aleea Ghioceilor Street, Bac ău. 5 Underground road passage building, between Oituz Street and tefan Gu e Street, Bac ău. 6 Rehabilitation and modernization of the “Leisure Island”. 7 The building of the City Hospital from Bac ău. 8 The repair of the historical building and of patrimony – “ House of Vasile Alecsandri ” from Bac ău. 9 The building of a pleasure resort at the forest from « Tama ». 10 Rehabilitation, modernization and equipment endowment at the Social Centre from No.9 Henri Coand ă Street, Bac ău. 11 The infrastructure rehabilitation of the “ Pneumoftiziologie” Hospital Bac ău, with ambulatory system . 12 Rehabilitation of urban streets from Bac ău City. 13 Professional Training Centre Bac ău. 14 Rehabilitation of the cultural objective “ The summer Theatre ” Bac ău. 15 Thermal rehabilitation of housing from Bac ău, of internal instalment for thermal energy. 16 Temporary Accommodation Centre for the homeless persons from the Bac ău City. 17 Secondary networks rehabilitation of thermal distribution from the Bac ău City. 18 Building of the Bac ău Urgency County Hospital.

19 The Park arrangement from Unirii Avenue, central area of Bac ău City.

20 Building of the Sportive Centre, formed of: football stadium as in UEFA, athletics stadium as in IAAF, gym. 21 Building of the Bac ău beltway.

The Main Problems Concerning Health in the City of Bacau

The Public Health Bacau has in subordination the public health units in from the county of Bacau and coordinates the private health establishments. They are organised according to the table below:

Medical units City of Bacau Total on t he Bacau County Medical units for ambulatory recovery 5 12 Units for medical care at home 2 5 Emergency medical units 2 2 Public hospital medical units 3 7 Private hospital medical units 2 4 Family Medicine Cabinets 98 296 Dental Cabinets 74 155 Pharmacies 54 102 Medical analysis laboratories 18 24

Some of the health problems of the Bacau Municipality are: • Increasing the number of people with severe chronic diseases: diabetes, cardio-vascular diseases, cerebral vascular diseases, cirrhosis and chronic hepatitis, malignant tumours; • Reduced access to the homecare services, for recovery or for palliative care; • The poor public awareness regarding healthy lifestyle; • Reduced number of specialty medical personal from the emergency medical assistance; • Absence of permanent centres through which it is assured the continuity of the primary medical assistance; • Establishment of a promotion strategy for the National Program of Health Evaluation; • Approximate 50% from the estimated population present a risk in developing a chronic affection.

Indicators of sickness, the incidence on causes and on age groups, shows that in the year 2007 the incidence of diseases has decreased and for approximately 50% from the groups of disease. There have been registered increased values for the nutrition and the metabolism diseases in all age groups and for the nervous system diseases in age groups between 1-14 years and more than 65 years. This decline may be a consequence of the decreasing population, educational campaigns organized by ASPJ Bacau, campaigns that have as purpose the increasing of the public awareness regarding the adoption of a healthy lifestyle. The same trend of the sickness indicators is registered at the country level. Nevertheless, analyzing the assessment of the health status of the population in the period 1.07.2007 - 30.06.2008, it shows us that the population of Bacau County has an increased risk of disease for the following conditions: diabetes mellitus type II, cardiovascular diseases, uterine, cervix uteri and breast cancers.

Theme 1: Health Impact Assessment (HIA) and the use of urban health indicators

Our city has no experience in HIA. In the private system of healthcare functioned in 2005: one hospital which offered 9 beds (9,3% from the total number per district). The private sanitary network was represented by 7 medical cabinets for families (28,0% from the total number per district), 7 medical cabinets for general medicine (38,9% from the total number per district) and 63 dentist cabinets which represent 56,8% from the district. There were, in 2005, 4 private pharmaceutical points in the Bacau Municipality (19,0% from the total number per district), and 60 units of pharmacies (56,6%). In Bacau Municipality, in the private system, functioned in 2005, 33 speciality medicine cabinets (63,9% from the total number per district), 11 medical laboratories (64,7% from the total number per district) and 45 laboratories of dental technique (51,1% from the total number).

At district level, there are 7 pharmaceutical stores, all these being situated in Bacau Municipality. The beds coefficient is an indicator calculated at 1000 or at 10000 per inhabitant. In Bacau Municipality the coefficient of beds assurance in the hospitals from the public health sector was in 2005, of 9,2 beds at 1000 inhabitants, this means that one bed from the Municipality Hospital is occupied by 109,2 inhabitants. In the sanitary resources a major place is occupied by the medical personal. In the public system of healthcare activated in 2005, 429 doctors in the Bacau Municipality (48,0% from the total number per district). At 31 December 2005, there were 102 family doctors, which means 23,8% from the total number of doctors and 32,8% from the total number of family doctors from the district. In December 2005, the total number of dentists who worked in the public sector from the Bacau Municipality was of 86 (47,0% from the total number of dentists of the district). There were registered 52,4% from the total number of medium sanitary personal. In 2005 activated 12 pharmacologists (66,7% from the total number per district).

Indicators: • Bacău Municipality Population = 179442 • Number of doctors = 435 • Number of assistants = 1193 • Number of dentist cabinets = 77 • Number of pharmacies = 77 • Number of medical laboratories = 13

Statistic data: – Natural spore = 0,0 %o in the first 9 months of the year 2007. – Born children = 10,6 %o in the first 9 months of the year 2007. – General mortality = 10,5 %o in the first 9 months of the year 2007. – According to the family doctors analysis we can observe the growing of the patients with affections to the circulatory system (HTA, ischemic disease/coronary heart disease) and the diminution of the patients with affections to the digestive system (ulcer, cirrhosis, hepatitis).

Patients took in evidence – Bacau Year 2006 TBC: 216 Diabetes: 3841 B Hepatitis: 10 Cardiovascular affections:29722 Cancer: 1412 Contagiousness and parasitic diseases: 1422

Patients took in evidence – Bacau Year 2007 TBC: 201 Diabetes: 4734 B Hepatitis: 5 Cardiovascular affections: 31982 Cancer: 1477 Contagiousness and parasitic diseases: 2254

The Monitoring Network

Monitoring of the environmental factors is developed through: 1. Analyses, measurements, which have in mind a wide range of physical-chemical, bacteriological, radioactive and sound analyses performed by their own laboratory and being realized on air, water, soil, vegetation: - in accordance with the annual plans for monitoring and verification of the compliance against regulatory acts; - at request, solicitation from internal and external customers. 2. Inventory of emissions from the economic units, from sources in the surface area and from traffic in the county. 3. Receiving and processing the information from the other institutions with responsibilities in the environment field.

Romania uses, at national level, a wide range of health indicators, having an experience of over 30 years. Locally the informational data are collected from all the health units, they are centralized and processed at the county level, and then transmitted to the National Centre for the Organization and the Assurance of the Informational and the Informatics System in the Field of Health Bucharest, where they are processed both in structure and in dynamic and they are communicated to the Ministry of Public Health or to other institutions which examines the health status of the populations and assess the effectiveness of health institutions. The health indicators are also transmitted to the County Institute of Statistics, to the Institute of Public Health Ia i, to the Centre for Prevention and Control of Diseases Bucharest and to the Ministry of Public Health. The health indicators that were used are divided into 6 categories: demographic indicators, indicators of sickness, indicators for assessing the work of health institutions, indicators of resources, indicators of medical and health personnel and indicators of health expenditure. The demographic indicators include: • The population and the population distribution on age group and sex • Number of born alive and birth indices • Female fertility, pregnant women taken in evidence, the number of abortions • General mortality on age group, mortality indices, the indices of infant mortality, mortality by groups of medical causes of death • The natural increase of the population, life expectancy at birth Indicators of sickness include: • The new cases and the incidence through the infectious and parasitic diseases (tuberculosis, syphilis, gonorrhoea, dysentery, typhoid fever, viral hepatitis, rubella, measles, scarlet fever, chickenpox, tetanus, convulsive cough) • The temporary inability of working after the main causes • General morbidity on classes of disease • The specific incidence on 17 groups of diseases • Number of patients who leave the hospital, on class of diseases, the frequency of hospitalizations on classes of diseases. Indicators for assessing the work of health institutions include: • Number of consultations and treatments on specialties, per inhabitant, medical cabinets, ambulatory and hospitals • Number of hospitalized persons • Days of hospitalization per person • Using the hospital beds on the wards (internals, surgery, gynaecology-obstetrics, paediatrics, neurology, psychiatry, ENT, ophthalmology) • The average duration of the hospitalization in a hospital, per wards (internals, surgery, gynaecology-obstetrics, paediatrics, neurology, psychiatry, ENT, ophthalmology) The indicators of resources include:

• Number of hospitals, ambulatories, family medicine cabinets, pharmacies, medical laboratories, dental cabinets, specialty cabinets. • Number of beds in hospitals on specialties/fields The indicators of medical and health personal include: • Number of doctors, dentists, pharmacists, health personnel, personal assistants • Ensuring the population with doctors, dentists, pharmacists, health personnel, personal assistants

Health Indicators:

• Total expenditures in the hospital, for a bed, for a sick, for a day hospitalisation • Expenditure on medicines in the hospital, for a bed, for a sick, for a day hospitalisation • Expenditure on medicines per internals, surgery, obstetrics-gynaecology, paediatrics Reporting the indicators by the health units it is be made monthly, quarterly and annually. The most used indicators are the demographic indicators and the indicators of sickness. The indicators of sickness show us a constant increase in the prevalence of the patients with chronic diseases such as diabetes mellitus, cardio-vascular diseases, cirrhosis and chronic hepatitis, malignant tumours. Since 2008, by the order of the Ministry of Public Health, in November, there were introduced some groups of health indicators, reported on the age group and on sex: • determinants of health state, based on the results of the national program regarding the assessment of the health status of the population in primary health care, the program began on 1.07.2007; • the prevention and the health promotion indicators include: vaccine coverage, screenings (prenatal, neonatal, breast cancer and cervix uteri), the number of campaigns to promote healthy behaviour and mental health.

Assessment of the Health Impact Bacau Municipality has no experience in assessing the impact on the health of the population.

Our expectations as regards the implementation of HIA and of a set or urban health indicators in our city, are: 1. Implementation of the national health programs which respond to the primary problems of public health and to the needs of vulnerable groups; 2. Capacity development of the rapid reaction to the health threats; 3. Reducing the transferable diseases with major impact (HIV, tuberculosis, infections with sexual transfer), and the chronic diseases as well; 4. Organizing prevention actions, addressing to the population with a high degree of infection; 5. Promoting health through interventions towards the determinants of health estate; 6. Moving attention towards the preventive health services and developing the educational level of the population in order to raise the standard of living; 7. Developing, modernizing the infrastructure of the medical services and their endowment with medical equipment and specific means of transport: – Building an emergency regional hospital and a municipal one in Bacau – with Cohesion and Structural Funds and local, national funds; – Rehabilitation of existent hospitals ; – Endowment with medical equipment; – Endowment with specific means of transport for medical emergencies. 8. Assuring the continuity of the medical act by developing the domicile treatment, the primary medical assistance and the specialty services given in the ambulatory; 9. Developing the professional qualifications of the medical personal;

10. Identifying some facilities for attracting the medical personal; 11. Unit medical practices based on guides of practice and on clinical protocols; 12. Growing the living standards and the quality of life, by improving quality and the medical act; 13. Growing the patients satisfaction; 14. Growing the medical personal satisfaction; 15. Growing the quality life for all the people of the town, including the people which are living on the South Area of the City – the critical area; 16. Improving the activity indicators of the medical units; 17. Promoting and Developing an Action Local Plan for a “good and healthily life”; 18. It’s important to develop and to finish some projects, because it’s necessary to have an support for our Local Action Plan: - The « UNIRII 3 »Park Development – 6.730 m2 and another identical projects; - The « Nicolae Balcescu » Ramp (greensward and plants) – 120.331 m2; - To develop the green spaces surface in our city.

On the moment, in Bacau Municipality, there is this situation: • Green spaces between the habitations – 115.700 m2; • Free lands, unproductive – 56.200 m2; • Green space in the yard of the new Municipal Hospital – 4.322 m2; • Green spaces around the institutions, economical and social-cultural units – 67.700 m2.

Propositions of realizing green spaces until 2010: - Total surface: 378.283 m2 (2,16 m2/ inhabitant).

Propositions of realizing green spaces until 2013: - Total surface: 1.050.000 m2 (6 m2/ inhabitant) : - Parks – 500.000 m2 - Green spaces between the habitations, around the institutions, economical and social- cultural institutions – 550.000 m2.

Theme 2: Policies and actions for an active and healthy ageing

Under these conditions, the initiation, the developing and the attribution of social and health services, especially those of personal care, impose and unitary policy in the domain for maintaining the old persons at their domicile or, if this is not possible, for assuring the necessary support in continuing their life in an institution of social assistance. In this way, The Office of Old Persons assures the social protection according to Law 17/2000 and to Decree 541/2005: - Hospitalization in the Old People Shelter of Bacau; - Inclusion in the attendance program at the domicile, developed in partnership with NGO’s; - Orientation of old people towards the day centres. Nowadays, in Bacau Municipality functions: a) An institution of social assistance for old persons, with a capacity of 212 beds; b) Following a selection, there were selected three NGO’s, which will receive non reimbursed financing according to Law 350/2005, NGO’s which will sign partnerships with the Public Service of Social Assistance and they will assure the attendance at the domicile of the old persons, without any contribution from the part of the beneficiary;

c) Following a selection, it was chosen a NGO, which will sign a partnership with the Public Service of Social Assistance. This NGO will assure services of education, counselling, recovering and treatment. The old persons which detain a high degree of handicap can benefit of a personal assistant or they can choose a payment.

STRATEGY OF WORK: Identifying and analyzing the needs of the old people in order to establish a plan of intervention: a) For the persons who cannot move: - daily help for the domestic activities or assuring the food at their domicile, by including them in the program; - medical assistance at the domicile, by including them in the program; - offering kinetic therapy services at the domicile, by including them in the program; - psychological counselling at the domicile, by including them in the program; -guiding them towards the Commission of Medical Examination in order to register them with a handicap degree. In this way they can benefit of a companion; b) For the persons who can move: - guiding them towards day centres, in which there are assured kinetic therapy services, psychological counselling, entertainment services, socialization; c) For the persons who need permanent supervision: - hospitalization in a shelter.

SERVICES OF DOMICILE ATTENDANCE – a) Main services: help for personal care, dressing, undressing, alimentation and hydration, transfer and mobilization, movement, communication – b) Support services: help for preparing food, shopping, household activities, visit to the doctor or to other institutions. – The purpose of these services: – - assuring to the old people a decent and a dignified life, keeping autonomy as long as possible; – - attributing support in order to maintain the safety and the comfort standard; – - attributing support in order to face the daily activities.

SERVICES IN THE DAILY CENTRE: – Group activities (playing, journeys, musical auditions, painting courses, chorus); – Social and administrative counselling (guiding them towards different institutions, intercessions for obtaining some rights); – Activities of spending the free time; – Engaging them in social and cultural activities; – Educational and health programs; – Kinetic therapy in a special room of the day centre in order to rebuild the physical capacities.

SERVICES OF ATTENDANCE IN THE SHELTER FOR THE OLD PERSONS: – main services: help for personal care, dressing and undressing, alimentation and hydration, transfer and mobilization, interior movement, communication, support for the rehabilitation of the physical and mental capacities, consulting and treatments, equipment assurance; – support services: administrative and juridical counselling, preventing the social marginalization, slowing the declension rhythm due to ageing, support for preparing food, shopping, domestic activities, visiting the doctor or other institutions.

The services of the Day Centre « The Pensioners Club » (opened)

1. The services offered by the Day Centre “The pensioners Club” are: – Social, psychological and juridical counselling. – Ergo therapy (occupational therapy), game therapy, music therapy, socializing activities, cultural-artistic activities, recreated activities (watching TV, group games, journeys); – Preventive kinetic therapy and therapy of recovering, according to the doctor’s advice, and according to the Individualized Plan of Intervention, in which it will be followed the improvement of the patient.

2. The beneficiaries of the Day Centre “The Pensioners Club” are the persons who are pensioners, who have the legal domicile in the Bacau Municipality or are residents, no matter the gender, nationality, religion. Priors are the old persons socially isolated in order to include them in the society.

3. Main principles of the Day Centre “The pensioners Club”: – The principle of respecting the human rights; – The principle of promoting the social inclusion; – The principle of equal rights; The principle of cooperation and of partnership.

The Project 'Network of home care for the elderly persons - a working model in partnership'

Concrete objectives 1. Improving the quality of life of the elderly persons by providing: - social services; - medical services; - basic care. 2. Developing the project visibility on the local and the national level and the promotion of the services for the elderly persons: - editing the county plan of services for the elderly persons; - collaboration with the NGO’s; - organizing in Bacau a regional seminar of community services.

What does it represent? Planning services for elderly people at the county level of Bacau is a starting point for the more efficient organization of the existing services and it establishes new qualitative services which can respond to the real needs of the elderly persons.

Creation of the county partnership In the Bacau County there was created an informal partnership, made of: - General Directorate of Social Assistance and Child Protection Bacau - The Town Halls from the 85 communes and the 8 cities - The House of Pensions of the Bacau County. - The County Administrative Office of the databases for the evidence of persons in Bacau. - The Public Health Authority from Bacau - Department of Labor and Social Protection Bacau. - The County House of Health Insurance Bacau - Representatives of the elderly persons from the Bacau County

This document aims to provide the following information: • The main needs of the elderly persons from the Bacau County;

• Priorities at which the social services should respond; • The need of financing; • It provides a strategic overview of the problems faced in the development and the administration of the district from the social field for the elderly persons under the current legislation.

Objectives - priorities:

1. Developing a coherent system of socio-medical assistance for the elderly persons restrained at their home. 2. Reducing the feeling of solitude and isolation felt by the elderly people by creating and developing adequate services which would integrate them in the community life. 3. Improving the health care assured for the elderly persons 4. Expanding the supply of social services, this will respond to the needs of the elderly persons. 5. Improving the legislation on social protection of the elderly persons. 6. Creating a special fund for the serious/urgent social cases of the elderly persons.

Theme 3: Healthy Places and Healthy Environment

The main issues and local needs:

1. the need to implement a project of urban regeneration in several neighbourhoods of the city, and especially in the south area; 2. increasing the green area of the city per inhabitant, in accordance with the rules set by the European Union; 3. the diminution and the elimination of pollution having as source the economic agents from the city; 4. clean air and healthy drinking water; 5. Reducing the discrepancies between the areas of the city, regarding infrastructure of streets and utilities, service quality and standards of living; 6. increasing the number of areas for leisure and entertainment; 7. improving the quality of life by enhancing the quality of medical services and of the social assistance, the consumer protection and the economic development as in the other regions of the EU, but also by promoting healthy living standards (healthy supply and outdoors moving). 8. To resolve some of the health problems of the Bacau Municipality, like this: • Increasing the number of people with severe chronic diseases: diabetes, cardio-vascular diseases, cerebral vascular diseases, cirrhosis and chronic hepatitis, malignant tumours; • Reduced access to the homecare services, for recovery or for palliative care; The poor public awareness regarding healthy lifestyle.

Concrete actions developed in health problems: – Monitoring the way in which there are respected the quality criteria of the medical act, at hospital level and at the level of the primary medical assistance, through mixed inspections realized by CAS Bacau (Health Assurance Bureau); – Objective evaluation for the need of specialty personal according to the recommendations of MSP; – The support of authorized institutions for professional training through continuous medical education of the medical personal; – Monitoring the developing of the national health programs;

– IEC CAMPAIGNES for the problems of public health identified at local or national level for emergency situations; – Participation to the European Week of Immunization by organizing workshops, sessions of training with community assistants and sanitary mediators regarding the importance of vaccinations; – Immunisation actions in communities that do not have access to the health services; – Lifestyle and health; – Preventing contraction through respiratory viruses and flu; – The woman’s health: breast and cervix cancer; – National Day without Tobacco; – Preventing the negative effects of the sultriness/broiler.

Strategic Objectives of the Bacau Municipality for healthy places:

– Encouraging a healthy business local environment – Equidistant physicality towards all the social and professional categories and towards the economical operators. – Healthy environment and improvement the quality of life through: – social and cultural life for all the social categories; – reaching the European standards for the quality of air, soil and water; – implementation of a program by which we enlarge the green space per inhabitant – thermal rehabilitation and replacing the sanitary installations at the buildings constructed in the period 1950 – 1990. – Implementation of the program “The Integrated management of the Wastes” – Rehabilitation of the sportive bases and building new sportive centres. – Creation of entertainment places for spending the free time.

Objective: The Municipal Hospital from Bac ău

– the first public hospital which will be build in Romania after 1989 – 42 millions Euro, the total value of the intervention – 3 September 2007, signing the contract of execution and endowment with techno-medical equipments – ICCO – Philips (Holland) and Integrine Brasov, the constructors – 760 days, the period of execution – modern medical equipments – 495 new jobs investment approved by the Romanian Government.

We propose to implement an action plan in the southern area of the Bacau City that would have as an effect its transformation into a healthy place. Issues: - it is an industrial area where it activates economic polluters agents (Amurco, CET - produces heat energy for the city, another company); - this area has a deficit of green spaces; - it is an area where the City Hall now invests in the rehabilitation and in the modernization of the infrastructure of the roads and of the utilities; - there are not adequate spaces for medical assistance; - it is an area with a population that contains people who need social assistance; - there are no places designed for leisure time.

We also propose to implement an action plan in the southern area of the Bacau City that would have as an effect its transformation into a healthy place. Issues: - it is an industrial area where it activates economic polluters agents (Amurco, CET - produces heat energy for the city, another company); - this area has a deficit of green spaces; - it is an area where the City Hall now invests in the rehabilitation and in the modernization of the infrastructure of the roads and of the utilities; - there are not adequate spaces for medical assistance; - it is an area with a population that contains people who need social assistance; - there are no places designed for leisure time.

Theme 4: Use of Structural Funds in designing actions to develop "health gains"

FSC – Structural and Cohesion Funds for North-East Region from Romania Priority Axis 3: Improvement of social infrastructure Objective This priority axis aims to create the premises for better access of the population to essential services, contributing to the achievement of the European objective of economic and social cohesion, by improving infrastructure for health, education, social and public safety in emergency situations. The key areas of intervention identified within this priority axis are: - Rehabilitation, modernisation and equipping of the health services’ infrastructure; - Rehabilitation, modernization, development and equipping of social services infrastructure; - Improving the equipments of the operational units for public safety interventions in emergency situations; - Rehabilitation, modernization, development and equipping of pre–university, university education and continuous vocational training infrastructure. 1. Rehabilitation, modernization and equipping of health services’ infrastructure Indicative operations will focus on: - Rehabilitation, modernization and equipping of the county hospitals; - Rehabilitation, modernisation, development and equipping of outpatient departments (hospitals and specialized outpatient). 2. Rehabilitation, modernization, development and equipping of social services’ infrastructure. Indicative operations will focus on: - Rehabilitation, modernization, development and equipping of the multifunctional social centres buildings; - Rehabilitation, modernization and equipping of the residential social centers buildings. - Improving the equipment of operational units for public safety interventions in emergency situations Indicative operations will focus on: - Specific vehicles and other related equipments for the regional & county operational units for interventions in emergency situations. - Rehabilitation, modernisation, development and equipping of pre-university, university education and continuous vocational training infrastructure Indicative operations will focus on: - Rehabilitation, modernization, equipping of schools and university infrastructure; - Setting up and development of pre-university campuses;

- Rehabilitation, modernization, equipping of the Centres for Adult Continuous Vocational Training. Priority Axis 4: Strengthening the regional and local business environment Objective This priority axis aims to set up and develop business support structures of regional and local importance, rehabilitate industrial sites and support regional and local entrepreneurial initiatives, in order to facilitate job creation and sustainable economic growth. Key Areas of Intervention - Development of sustainable business support structures of regional and local importance - Rehabilitation of unused polluted industrial sites and preparation for new activities - Support the development of micro-enterprises Development of sustainable business support structures of regional and local importance Indicative operations will focus on: – The setting-up and development of the different types of regional business support structures (BSS): – Construction/rehabilitation /extension of buildings only for productive and services activities; – Rehabilitation/extension of the internal road system inside the location and also the access roads; – Set up/rehabilitation/ modernization/extension of the basic utilities (water, sewage, natural gas and electricity networks); – Cabling, internet broadband networks etc.; – Buildings demolition; – Promotion activities; – Extension of the BSS (waste removal, cleaning, etc); – Other related activities needed to set up/develop business structures Support the development of micro-enterprises Indicative operations will focus on: – Support to micro-enterprises’ development – Procurement of equipments and modern productive technologies, services, constructions; – Procurement of IT systems (software and equipments); – Use of new technologies in the current activities of micro-enterprises; – Relocation of the micro-enterprises in business structure; – Extension/ construction/ rehabilitation/ modernization of the micro- enterprises production spaces; – Specific development activities.

Some Projects for Bac ău City: Investments are made with more and more European Funds, non reimbursable. This aspect confirms the fact that the European Authorities trust the Bacau local administration: – Building subterranean roadway between the streets Oituz and Stefan Guse, ROP – Axe 2, total estimated value of the investment: 8 millions Euros; – Rehabilitation of the buildings and modernization of the Social Centre from the street Henri Coanda, ROP – Axe 3, total estimated value of the investment: 900 000 Euros; – Rehabilitation and endowment with equipments of the Old People Social Centre, from the street Aleea Ghioceilor, total estimated value of the investment: 760 000 Euros; – Rehabilitation and modernization of the Entertainment Island, ROP – Axe 5, total estimated value of the investment: 5 millions Euros; – Building an Entertainment and Tourism Centre – The Tamas Forest, ROP – Axe 5, estimated value of the investment: 10 millions Euros; – Expositional and Business Centre. Project approved with a total value of 14 millions Euros.

For all these projects has been signed the financing contracts for technique assistance.

The « UNIRII 3 » Park Project – 6.730 m2 (Government and Local Funds); Improvement of the supply systems of water, collection and treatment of wastewater in the city of Bacau, Bacau County (ISPA measure No. 2002/RO/16/P/PE/018);

Beneficiary: Autonomous Management Direction of Bacau Component A Adduction raw water pipeline Component B New treatment station of the raw water Component C Rehabilitation of sewerage networks in the city of Bacau Component D Rehabilitation of the wastewater treatment station in the city of Bacau The value of the project: 52.056.000 Euro (non reimbursable funds ISPA: 39.004.500 Euro)

Integrated management of wastes in the city of Bacau and in the surrounding areas in (ISPA measure 2004/RO/16/P/PE/007);

Beneficiary: Bac ău Local Council and the Local Councils of the localities included in the project Localization: the City of Bacau and the 22 localities situated surrounding the City of Bacau. Component 1: Closing the waste store of the Bacau City Component 2: The closure of uncontrolled stores from the rural areas Component 3: The construction of the new waste store Component 4: The collection of waste in the city of Bacau Component 5: The collection of wastes in the rural areas Component 7: Technical assistance for the public – private partnership (PPP) Component 6: Technical assistance and surveillance The value of the project: 20.000.000 Euro (75% through the non reimbursable financial assistance ISPA)

Equipping 'The Sportive Park Complex' - with an area of 2.93 hectares which consists in creating new green space on an area representing 75% of the total area and in the arrangement of a leisure space that includes facilities and play spaces for children. The total value of the project is that of 560.000 euro (Government Funds);

Equipping the public space for spending the leisure time from the central area of the city, being an area of entertainment and of recreation where we can develop some public meetings (local funds).

We need programs funded by the European Union in order to develop the following projects affecting the health problems and the quality of life:

- supporting the sustainable development of the Bacau City - urban growth pole (Goal: enhancing the quality of life and the creation of new jobs in cities, by the rehabilitation of the urban infrastructure and by improving the urban services, including social services and by developing the structures to support business and entrepreneurship); - development of Bacau metropolitan area as a new form of partnerships and territorial governance among urban and rural areas for the development and the promotion of the region; - promoting a policy of European territorial cooperation so Bacau Municipality to make part of a regional group of competition and innovation in the EU; - development of green areas and of recreational areas; - enhancing the quality of medical services and of social assistance;

- development and rehabilitation of areas and of tourist targets; - development and rehabilitation of transport infrastructure and of public utilities; implementing a program of cultural exchanges with the regions in the EU.

IMPACT AND OUTCOMES

It’s important like this proposal to realise the following projected results/outcomes/outputs: 1. Creating an action learning exchange for over 10 key actors from our city; 2. Establishment of 1 Local Support Group; 3. 3 sub-theme reports ; 4. 3 sub-theme linked case-study reports-incorporating at least 40 case studies; 5. An online resource relating to the specific sub-themes; 6. 1 action plan linked to funding sources at EU, National and local levels; 7. Establishment on online interactive platform; 8. Dissemination of results to at least 30 other Cities; 9. Generate guidelines for future interventions in relation to European, national, regional and local levels.

Sources 1. Documents which are the basis for the environmental information: - The Local Action Plan for the Environment Protection, elaborated by EPA Bacau in the period 2004 – 2005, approved by the Decree of the County Council No. 153/29.11.2005; - Report on the State of the Environment in the Bacau County for the year 2007, prepared by the EPA Bacau; - GPO 195/2005 concerning the environmental protection, updated with the subsequent modifications and completions (Law 265/2006 and 114/2007 GPO); - STAS 12574/1987 and the Order 592/2002 concerning the maximum permitted concentration of pollutants in the atmosphere; - Order 161/2006 regarding the classification of the surface waters; - STAS 10009/1988 regarding the noise level in the environment.

2. Documents which are the basis for the health information: - Ministry of Public Health, the National Center for the Organization and the Assurance of the Information System in the Field of Health Bucharest, the Statistical Yearbook of Health - 2006; - ASPJ Bacau, Department of Medical Informatics and Biostatistics, Centralizer for the medical activity, Reports regarding the main indicators of health knowledge, 2003 - 2008; - ASPJ Bacau, the Office of health promoting, Activity Reports, 2005 - 2007; - CJAS Bacau, Analysis of the Assessment Program of the health state of the population in primary medical care, 1.07.2007 - 30.06.2008. • ASPJ – Public Health Authority of the County • CJAS – CJAS Bacau, Analysis of the Assessment Program of the health state of the population in primary medical care, 1.07.2007 - 30.06.2008.

3. The Bacau Municipality Strategy and the documents of Local Administration which are describe our projects for local development.

4. The Local Development Agency Strategy for implementing a good life in Bacau City and for Territorially European Cooperation.

Baia Mare - Romania

Dorin Miclaus Municipality of Baia Mare – Strategy Department 28 th of July 2008

General socio-economic context: current situation and main issues related to health

Baia Mare ancient name: Rivulus Dominarum , name in Hungarian: Nagybánya , German: Frauenbach and seldom Neustadt ) is an important city in northern Romania and the seat of Maramure County. It is located in the northern part of the county, on the middle course of the Săsar River, at an average altitude of 228 metres, surrounded by the Igni and Gutâi mountains. The city has an area of 233 km² and also contains the following settlements: Blidari, Firiza, Valea Neagr ă (The Black Valley) and Valea Borcutului. In terms of area, Baia Mare, including the previously mentioned settlements and the forests within the city limits, is one of the largest cities in Romania, being a few square miles larger than the country's capital, Bucharest. However, it is ranked 17th in terms of population. Due to the concentration of economic activities found in the city and their importance, Baia Mare ranks third in northwest Romania, after Cluj Napoca and Oradea.

Population The census of 1930 indicates a population of about 14000 inhabitants. Today the town has grown into a city numbering around 150000 inhabitants. Before 1989 most of them were employed in the mining industry and in the others connected to it. Owing to its present achievements the municipality of Baia Mare proves to be an important urban centre in this part of the country, developing in a dynamic pace. New economic activities join the traditional ones. The municipality of Baia Mare had a total population of 137,976 in 2002 , the majority being Romanians. The city is also home to a sizeable Hungarian community. The diverse ethnic composition of the city is as follows: Romanian: (82.81%); Hungarian:(14.84%); Roma:(1.51%); German:(0.36%); Ukrainian: (0.25%); Jews: (0,10%) and 642 others, including Greeks, Turks, Italians, Poles, Swabians and Slovaks.

Economy The economical activity of Baia Mare has been built around the mining activities located in the surrounding areas. However, after the 1989 Revolution these mining activities have decreased visibly, being replaced with several activities which have improved the city's economy in recent

years. Nowadays, Baia Mare has become one of the most economically evolved cities in the region. As a result, several supermarkets have been built in the city and at least 3 malls are due to open for the public no later than December 2008. As well, the largest sofa manufacturing plant in Eastern Europe, Italsofa, is located near the Baia Mare city ring. The road infrastructure within the city is changing to be able to better connect the city and absorb the traffic on the express road which is to be built between Petea (at the border with Hungary) and Baia Mare, a project for which the feasibility study has just completed. The express road will connect the cities of Baia Mare and Satu Mare to the Hungarian motorway M3 and thus the whole European motorway network.

Demographic Data for Baia Mare, 2006-2007 2006 2007

The number of inhabitants 140581 139870

Natality 10 9.42

Mortality 7.67 7.5

Child mortality 6.41 9.11

Death-natality ratio 3 2.27

Natural growth 326 268

Excedent 2.32 1.92

Neonatal mortality 4.99 5.32

Post-neonatal 1.43 3.8

The Population in Baia Mare Municipality at 1st July 2007

Year 2003 2004 2005 2006 2007

Inhabitants 142651 142355 141889 141521 139870

Population grouped on age

Life hope at born (2004-2006) for the inhabitans from Baia Mare Municipality

TOTAL Men Women 71,36 67,49 75,22

The Structure of Medical Services in 2008 for Baia Mare The medical and social service is realize by means of the sanitary network which comprise 3 hospitals, Medical offices for family practice, Private Dentists’ Offices and Pharmacies. Following distribution can be seen at the municipal level:

Doctors Awerage inhabita Populati medical Beds places/ doctors/ ns/ beds/ on specialis doctor 1000 sanitary 1000 ts inhabita specialis inhabita ns t ns Baia 142651 378 1514 1477 377,4 2,6 94,2 10,3 Mare

Public health units equipped with beds : - The “Dr. Constantin Opri ” Emergency County Hospital (1077) - The Phthisiology Hospital (270) - The Hospital for Contagious, Dermatology and Sexually Transmitted Diseases and Psychiatry (170) Private health units equipped with beds : - EUROMEDICA HOSPITAL - COSMEDICA INC

The Personnel Structure of Public Hospitals of Baia Mare in 2008

MEDICAL DOCTORS 221.5

OTHER SUPERIOR MEDICAL PERSONNEL 62

MEDICAL NURSES 1048

MEDICAL FEMALE NURSES 27

ORDERLIES 205

CAREGIVERS 396

Higher education non-operating personnel (S) and ( SSD) 49

Higher education non-operating personnel ( PL), (M) and (G) 72

Other positions requiring higher education (S) and ( SSD) 3

Other functions requiring higher education ( PL), (M) and (G) 21

Workers and security 240

Managers 3

Medical Managers 2

Accountancy and Financial Managers 3

Healthcare Manager 1

Administrative managers 2

TOTAL 2355,5

LABORATORIES (under contract with the HID): 7 - The St. Mary Polyclinic Joint Venture INC - The Gr ădinaru – Ciurtin INC - The Helcor Med INC - The Jersey Transylvania LTD - The Labormed INC - The Medcenter INC - The Sebestyen- Stoica – Ratiu Partnership Firm Community Healthcare (25 MM)– 1 community healthcare worker for Ferneziu and Firiza Sanitary Mediators (6) The RomMedica Centre within the Phthisiology Hospital – 4 for the areas of Pirit ă, Craica, Ferneziu and 2 for Colt ău Homecare (under contract with HID) : 5 - The White-Yellow Cross Foundation - The Caritas - St. Varvara Organisation - The Bobi Ńă Prod Com INC - The Medhelp INC - The Pro Life INC

The analysis of the specific indicators shows following: • A low number of inhabitans retaled to each doctor 377,4 inhabitans/doctor, as compared with the same figure for the entire county 678,3 inhabitans/doctor and respectively at the national level 522,3 inhabitans/doctor; • The inhabitans related to the sanitary specialist is 94,2, with figures under the awerage on the county level 194,5 and respectively at the national level 190,9; • The awerage number of beds related to 1000 inhabitans is 10,3 with figures over the awerage on the county level 7,6 and respectively at the national level 7,5 showing a relatively good capacity.

Priorities • The continuation of the process of service quality increase • The increase of prevention and major illness tracing activities

• The service package development according to the needs resulted from the PNESS • The increase of service accessibility for the disadvantaged • The identification of socially determined needs for medical services (UMS) • The continuation of investments for development and modernization of the health infrastructure and the endowment with specific equpment and transport means • Decentralization of some health programs • Development of the IT endowment • Human resources training • Institutional Partnerships (Public-Public; Public-Private and with the civil society) • Introduction of the Base Services (for the insured inhabitans) and of the urgency portfolio (for all the inhabitants) • Decentralization of the Sanitary System • Improvement of the data regarding the development of the public health. • Improved quick action to any health threats • Promotion of health and prevention of sickness – as the main approach.

SWOT ANALYSIS Strong points: – The number of services supplier, for each category of medical care, for each habitant. – The specialized team within the institutions which have attributions on the medical area – The existence of an important number of young people which is capable to adopt the new provisions imposed by the reform and the Law no. 95/2006 – The great number of NGO’s which are active and which can be attracted as partners in the medical and socio-medical domain The weak points: – The existence of services at the metropolitan level, concerning the quality and the geographical area. – The lack of an integrated informative system in order to connect all the medical service suppliers and also the institutions which have attributions in the medical domain. – The lack of the real, financial and managerial autonomy, this lack affects all the major aspects of the activities developed by the institutions that are accredited in the medical field. – The coexistence of the chronically and transmissible diseases. – The existence of those problems which are related on the lack of information concerning de family planning. Opportunities: – Decentralization an obtaining of a real autonomy by the local authorities involved in the medical domain, established as objectives in the ruling program. – The implementation of medical private assurance, which have, as a benefic result, the reduction of the social system oppressed by the pressure and the growing distiller coming from the population. – The effort of the local authorities which are trying to realize a strategically planning. – The UE integration – The development of competences within the medical system and also the quality of the medical act – The UE member status opens / offers new possibilities concerning the structural funds on projects – The possibilities for development that the medical “tourism” can offer with great benefits for the social and economic fields and also for the municipality Risks: Decentralization and giving a real autonomy to the authorities which have competences on the medical field might have some unexpected consequences.

This is why there are always questions like: • Does it exists at the local level, the potential and the managerial capacity in order to take all the specific functions existing in the medical system and its managerial capacity? • Does it exist a financial sustainability? • Does it exists any rely between the autonomy and the real reform? This autonomy must be corroborated with a real reform, capable to implement a managerial body which has competences at the level of each institution from the medical field. • 2. The arising on the market of private medical assurances. • The risk of loosing the human resources in the detriment of the private sector the qualified personal represents a resource that must be preserved and protected, especially viewing the tendencies of migration towards the private sector • The arising of a social gap between the persons who can afford themselves an extra assurance and those who are disfavored . • 3.The lack of capacities and managerial abilities at the assurances system level – for example, the hospital managers are still selected by the professional criteria of medical excellence ( the prestige, the performance, etc.) that are not always compatible with the managerial domain problem that is evidenced by the bad administration of the funds, difficult to quantify • 4. The existing risk that the chronicle and the transmissible diseases rise constantly, without a coherent and concrete intervention program. • 5. Due to the UE integration The rising costs of the medical assistance that can lead to a accentuation of the gap concerning the access to the medical care • 6. The rising of patient's information level concurrent with the progress and the diversification of diagnostics and therapeutically technologies will lead to a rise of the expectations and, of course,to a rise of the demand of complex medical services; the health system must dispose of mechanisms that can assure the canalizing of the financial resources according to the efficiency principle • 7. the development of the private system represents a competitive background for the public system. 8. the free circulation of persons and all the facilities created after the adhesion of Romania at the European Union in order to obtain more jobs; this fact misleads the risk of migration of the specialized personal, especially the performing and high-qualified one.

Theme 1: Health Impact Assessment (HIA) and the use of urban health indicators

There are no concrete actions related to HIA and to the urban health indicator. However some of the indicators are monitored, both local, regional and national. There is not a direct experience in HIA in Baia Mare, but the use of urban health indicators has started and there is a clear need to define a set of indicators (mainly related to the issue of the perception of safety and basic health care for weaker categories as elderly people and migrants) and to introduce HIA in the city regeneration strategies and policies However, we are using statistical HIA and related urban health indicators, mostly urban health indicators such as: - health indicators (mortality, low birth weight), - health service indicators (health education programme, percentage of children immunized, number of inhabitants per nurse,percentage covered by health insurance), - environmental indicators (pollution, waste collection and treatment, access to green space, public transport, sport and leisure), - socio-economic indicators (unemployment rate, percentage of disabled people employed, percentage of child care places for pre-school children.

We are not sure that they are the best ones therefore we would like to share European experience. The aim is to integrate HIA and health indicators into policy decisions and to draft a Health Strategy. We can consider also the use of indicators at National, regional and local level such as the ones used for the Urban Audit.

Expectations. - City’s increasing role in health and wellbeing / community planning - Strengthen competences in less known fields (e.g. HIA) and develop toolkits for the implementation of programmes/projects/actions - to promote the interaction of the relevant departments of the Municipality and to set concrete grounds towards this direction - Enhanced knowledge and skills - Develop the collaboration among institutional partners (Region, City) and private partners (NGOs, associations, …) - Help in influencing key stakeholders and to actively involve and interconnect all the relevant actors - Find a structure for implementation, policy making and measurements - To practically familiarise the relevant health actors with HIA & with the establishment of urban health indicators : a great potential especially through the inter-municipal network of health structures - Identify areas for future work - Define an area of the city as a strategic area to experiment the outcomes of BHC in terms of tools and guidelines - Gain knowledge and develop our work to be a more healthy city – putting theory into practice - Exchange our experience of using health as a brand - To develop a coherent and responsive local strategy for urban and sustainable development - To gain experiences from other European cities, to exchange information and experiences and to create administrative conditions for the implementation of ‘healthy’ cities’ strategies in our Municipality/ country - To place the issue of health even further up on the social and political agenda of our Municipality Funding opportunities based on the drafted Health Strategy

Theme 2: Policies and actions for an active and healthy ageing

Social development in Baia Mare City points out the interdependence between the different sub- domains of the local social development, the institutional responsibilities and areas of competence, the vulnerable target groups of the social interventions, the community factors that favour the growth of efficiency and efficacy of the social intervention. Accomplishing a satisfactory level of welfare can be realized only through projects of urban regeneration (rehabilitation of the collective economic conditions, infrastructure, territorial sets, development of the economic activities capacity, etc.) and allocation of community resources. Problems at municipality level: - lack of social policies for elder people; - the unemployment of the persons over 45 years and rroma persons; - lack of social infrastructure (we are now in the phase of looking for financing sources/ solutions).

The most important problem of the third age persons is the lack of an occupation and of a motivation to carry on living an active life. The occupational therapy services at the municipal level are not sensed inside the target group. According to a questionnaire applied to this target group, during a recent social research study, 77% of the elder live in a block of flats, 50% of the apartments have 2 rooms, and the majority of the families are formed of 2 persons, 25,3% of them being alone. 74,5% of the subjects said they would not participate as volunteers in community benefit actions, just 19,2% would. The Agency of Employment adopted this year a policy regarding the integration and reintegration of those persons that need support the most, due to the age legal barriers, respectively the persons over 45 years, facilitating their access to continuous training and ensuring benefits for those employers who hire this segment of population. At the local level, we now work on a Master Plan, reviewing the Local Sustainable Development Strategy (Local Agenda 21), two Urban Regeneration Projects (the social component). The social infrastructure is in course of rehabilitation and regards services for elder population, but, generally, it doesn’t respond to the needs of this disadvantaged vulnerable group. Concrete actions: - a Day Center for Elder Persons (CASPEV)- implemented; - creating 2 Elder Home Centers- in project phase; - services for assistance and home care (socio-medical services) for elder people in Baia Mare.

LEGISLATION on SPAS Involvement in Providing Medical Services - Law no. 47/2006 on the social assistance national system, which stipulates that the public service has as main attributions: to develop and manage specialised social services, among which are: hosting, nursing, recuperation, rehabilitation and social reinsertion for the elderly, disabled people, chronically diseased people, people addicted to alcohol or drugs, victims of domestic violence or of human beings traffic. - Law no. 272/2004 on child protection and on promoting child’s rights - Law no. 116/2002 on preventing and combatting social outskirting - Law no. 17/2000 on elderly social assistence - Law no. 275/2007 on protecting and promoting disabled people Sustaining Services with Socio-Medical Specific: 1. Subsidizing Human Resources Nurseries: medical assistants – 10 pers. Day Centers: – “Caspev” – 1 pers. med. as. “Luchian” – 1 pers. kinetotherapeut Center for children with autism – 2 pers. (psychologist-teacher and psychologist) Personal assistants for disabled people – 300 pers. 2. Financial Subsidizing of Nonprofit Social - Medical Activities Legal basis: Law no. 350/2005 –non refundable funding from the local budget Projects carried out in 2007 : A. More Informed People for a More Responsible Community –Caritas Organization Satu Mare, work site Baia Mare – 20,049.625 lei funded amount Purpose of the Project - to increasethe informing degree of the community members on home social-medical nursing services in the Baia Mare Municipality. Achievements - to increase the informing degree of the Baia mare community members on home social- medical nursing services, facilitating the access to social assistance by informing the 30 belongers /personal assistants on effective legislation regulations and their effective involvement within the nursing process by improving the home nursing technics and the life quality of elderly or disabled people.

B. Home Social-Medical Nursing- A Chance for Everyone - The White - Yellow Association - 40,876 lei - funded amount from the local budget Purpose of the Project - to improve the health condition of sickbed people or outpatients. Achievements - to increase own disease self-control capacity and the mobilizating capacity, concurrent to reducing the addiction degree;improving physical and social condition of the 248 patients, the elderly, people with precarious financial condition, chronically diseased people. 3. Facilitating the Provision of Medical services within the Local Social Centers’ Network: - All the social infrastructure projects promoted by SPAS (the local social centers’ network) contain rooms assigned for medical services. - E.g. Functional Social Centers: Elderly Day Center – CASPEV - E.g. Social Infrastructure Projects: o Community Center “Rromani” – CT41 o Social Center for the Victims of Domestic Violence – PT5 o Multifunctional Center such as Night Asylum –V. Alecsandri St. o Social Center for Children “Rivulus Pueris” - PT3 o Social Center for Disabled People – Police Station Mess Hall Elderly Day Center “Sf Anton” –Victoriei St.

A priority: the Local Action Plan in the Social Service Domain

The cycle of out skirting social exclusion shows that each problem leads to the other and all produce the same result – social marginalization. Thus, the lack of education leads to limited opportunities, limited opportunities lead to the lack of jobs, no job leads to no wages, that lead to insufficient incomes, precarious living conditions, precarious health state, that doesn’t permit getting an education. The surrounding environment has also influence upon the marginalized persons: the attitudes, the social patterns, the law, the ethnicity/ nationality, gender issues, disabilities, culture and traditionalism. Regarding the ageing population, they are affected by the small pensions, that doesn’t permit them to take care of their health, they face precarious living conditions, they are not involved in an active way of life (there is difficult to engage after the age of 40). The most important problem of the third age persons is the lack of an occupation and of a motivation to carry on living an active life. The occupational therapy services at the municipal level are not sensed inside the target group. According to a questionnaire applied to this target group, during a recent social research study, 77% of the elder live in a block of flats, 50% of the apartments have 2 rooms, and the majority of the families are formed of 2 persons, 25,3% of them being alone. 74,5% of the subjects said they would not participate as volunteers in community benefit actions, just 19,2% would.

Theme 3: Healthy Places and Healthy Environment

The link between healthy places and healthy environment is extremely important to our city due to the ancient / historical pollution and due to the proposed regeneration programmes. The main challenges in relation to this theme refers to the use of the public space as an healthy, friendly and safe space

STRATEGIC PROBLEMS:

• Lack of a real and effective capacity for analysis and prognosis - that has a negative affect also on conceiving a development strategic management plan. • Lack of financial authonomy of abbilitated institutions. • Incidence of transmissible or chronic diseases. • Incidence of problems linked to knowledge lack on services for family planning and reproduction health. • Management capacity at the level of the institutions abilitated in the health domain. • Focus on healthy urban planing • Sustainable, activity, safe and social • Private and public sector should be involved

Strategic Problems Identification: In the health field, it is foreseen to apply the Administration’s strategy and policy and to meet the reform within thid sector by organizing, coordinating and coaching activities in order to ensure population health, to prevent and disprove unhealthy practices by: - taking measures to promote a healthy life style by education campaigns according to the health calendar, informing papers on preventing tobacco, alcohol and drug consumption, improving children and women health condition; - carrying on the reforming process within the sanitary system by accreditting all the consulting rooms, monitoring the individual and stomatological medical activities; continuously forming and educating the personnel that develops health promoting activitities; - on-coming health and demographic indicators to civilized countries; - meeting citizens’s equal access to health care and increasing the medical act quality

Specific Measures at Departmental Level: Medical Services · Emergency Medicine—establishing the Emergency national Systems, provided by paramedics · Ambulatory Medicine—to reduce hospitalization · Family Medicine –councilling, education, prophilaxy · Home Nursing – medical assistants having private practice · Hospital Ambulatory Service – for ambulatory patients or affections that not require hospitalization · Stomathologic Care– increasing accessibility · Promoting Health – programs against drugs, alcohol, smoking, obesity, sedentarism, sexual transmission diseases

Strategies • Developing a Local and County Partnership which leads to emerge an organism specialized in lobby acctivities, representing the joint effort of the whole county or municipality in solving out their own problems; • According an increased importance to the analysis-prognosis activity, which to develop the system capacity of reacting concordant to the population needs; • Arising at the main principle of the dictum “preventing is better than healing”; • Emphasize the projects in prophilactic medical services domain, which, besides the evident benefits linked to the individual and community health, leads to financial efficiency, on medium and long term, of the sanitary sustem and also influences its capacity of responding more effectively to the community health needs. • The creation of an over institutional structure and of an interdisciplinary team at county/city level • Lobbying regarding the development of an integrated computer system • The carrying out of a comprehensive analysis of the city population’s health and the establishing of priorities and objectives

• The development of projects and partnerships regarding the field of prophylaxis • Information programmes regarding risk factors of major illnesses • Morbidity-reducing partnerships, particularly concerning illnesses that are substantial fund consumers • Projects concerning family planning and reproductive health • The development of programmes to increase managerial capacity, in cooperation with higher education institutions

The development of a website which should monitor and promote • The activity of the coordinating structure • The number of projects being carried out, their results etc. • The evolution of indicators being observed (regarding the incidence improvement of the main target illnesses)

Lobbying calendar and results (the creation of the integrated computer system, the granting of autonomy as well as other objectives that can be set regarding legislative modifications or system organization with a view to make response ways more effective and to adjust to the real needs of the population)

The Benefits for such an approach will be: • The gradual improvement of the city population’s health • The medium and long-term improvement of the incidence of main diseases as a result of prophylaxis projects and programmes being carried out • The long-term reduction of healthcare costs, which leads to possibly developing the medical service package provided by the social health system • The increase of management capacity and of the recruitment base of health managers

CONCRETE OBJECTIVES • The establishment of neighborhood PERMANENCE CENTRES to insure healthcare continuity. Patients cannot get access to their GP from 8 PM to 8 AM on weekdays, Saturdays, Sundays and legal holidays and as a result the number of demands for emergency services is very high • The establishment of SOCIAL HEALTHCARE UNITS and the development of HOMECARE SERVICES – the covering of the need for social healthcare services, the strengthening of community social work capacity and the cutting down of hospital healthcare costs • The establishment of Adult Residential Centers for people suffering from severe neuro-motor disabilities who live on their own and cannot afford to support themselves or to check into a home but can contribute to their support costs by means of their welfare funds. • The development of SPECIALISED AMBULATORY HEALTHCARE and of neighborhood MEDICAL LABORATORIES • City Hall support of city’s hospitals, including the support granted for the establishment of PRIVATE MICROPOLYCLINICS that would secure an increase in the quality of medical acts • The improvement of hygienically and sanitary conditions in schools and kindergartens • Information and awareness campaigns for citizens

• STRONGER INVOLVEMENT OF THE EXISTENT MEDICAL PERSONNEL WITHIN THE EDUCATION INSTITUTIONS in the prophylaxis of youth-specific conditions (e.g. spine deformities generated by extensive desk activities or computer work) and in the prevention of behavioral habits that are health-endangering (e.g. smoking and drug use). • The support of establishing dental prevention medical offices in neighborhood schools • THE IMPLEMENTATION OF a U.S.A. HEAD START or of a U.K. SURE START -type project that offers support to preschool children and their disadvantaged families. Support consists of the providing of: child education, parent-oriented classes for the developing of child-rearing and education abilities, social work and psychological counseling etc. Program benefits: each dollar invested meant five dollars saved in the long run by avoiding problems related to children’s health and by preventing delinquency; the high rate of social and professional success for the children included in this program. • The effective management of domestic waste • The structural rehabilitation of the City’s hospital network • The accordance with European models concerning both the infrastructure and the organization and functioning of emergency service system

It is very difficult to select an “unhealthy” part of our city because Baia Mare has had, until recently, a mono-economy based on mining with all its correlated processes (extracting, processing and stocking materials, etc.), and how you know both the mining industry and the related processing industry produce an “unhealthy” environment. ••• Given that Baia Mare is known as a "critical area from the viewpoint of pollution. in the region, despite its location in an attractive natural environment, a detailed dynamic and strategic analysis of the ecosystem has been provided". The utilization of natural resources and the rigorous pollution control are priorities with major impact on the strategy and the action plans in the context of the Local Agenda 21 ••• The challenges the city of Baia Mare has faced in the past several years, due to its evolution from a mining city to a modern one, have made it stronger and ready for the trends of the new millennium. The regeneration of urban activity in the old city centre, the introduction of modern community education, the promotion of the ?ideal city? vision, and the action plans of the Local Agenda 21 in accordance with sustainable development concepts, point to the implementation of total quality principles, in a typically Eastern European city entering a new millennium and new social structures. An important step in the evolution of the city is the change The Local Public Administration of Baia Mare takes full responsibility of the strict observance of the sustainable development principle, combining elements of cultural preservation and modernity in its strategic vision.

Theme 4: Use of Structural Funds in designing actions to develop "health gains"

Experience of working in related fields through transnational exchange has been made only by using pre-accession funds. The Social Assistance Public Service Baia Mare participated in a transnational collaboration project named SPER, in which were involved the communities from Torino, Rome – Italy, Barcelona, Granada- Spain, and another 5 cities from Romania. The persons from Social Assistance Public Service for the LSG are part of the group that elaborate the social component of the Baia Mare City Strategy.

Other comments

Urban regeneration is a challenge for the local and regional development in all EU member states from the perspective of the competitiveness of European cities in the global economy. In our view, urban regeneration in an exercise for managing change and the transition of cities in time, by taking into consideration the expectations of its residents, the potential for investments but in the mean time reaching the goals of environment and social welfare. Community Regeneration is defined as ‘intervention in disadvantaged localities and/or targeted at disadvantaged groups, aimed at economic, social and/or physical improvement, and involving some form of partnership working’. The implication is that special efforts are required in regeneration areas, beyond ‘conventional’ approaches operating elsewhere, including a more inclusive decision-making process and greater sensitivity to local conditions. The literature on urban competitiveness suggests two groups of ‘keys’ to innovation. The first concerns investments in ‘hard’ measures such as an efficient connectivity ; the qualification of the workforce ; and the transfer of knowledge between research centres and enterprises. Such measures are often the core of RDA and national policies, and are traditionally meant as directly influencing the development of the knowledge economy. The second concerns the liveability of a territory emerging from such factors as environment, culture and housing; and the elusive element of a strategic capacity to implement development strategies. These latter initiatives, albeit indirectly aimed to the economy, are becoming an apparent factor of success and are among the measures more easily in control of cities and local governments. In the recent years, some new neighbourhoods have been built, many others have shown a variety of approaches to transformation, becoming “new” in different ways: from the gentrification of historic centres to the conversion of industrial areas into technological districts. All these appear to be the key element of the creative city. Most of the rehabilitation processes aimed at city centres, brown fields or derelict lands are instrumental to the strategies of economic development; they offer the opportunity to test how liveability contributes to the creativity of cities; and how the agents of the knowledge economy are influenced by such initiatives. Knowledge districts providing innovation, though, do not necessarily coincide with technological districts. Innovation is a far larger process than technical improvement, and requires a change in people’s attitudes and relations. Such changes are made easier in certain urban environments providing for a rich and qualified urban life. Acknowledged features of such knowledge districts are both material and immaterial, such as: a dense settlement, a variety of cultures, a reflexive social opinion, a flexible job market, permanent education, etc. In fact, while most of the innovations heralded by new neighbourhoods are strictly related to planning, environment or urban design, some others address more directly the issue of liveability , creating efficient, serviced, and diverse areas (for instance, mixing functions and activities, hosting cultural institutions, providing affordable housing and different housing types). Mining causes the destruction of natural ecosystems through removal of soil and vegetation and burial beneath waste disposal sites. The restoration of mined land in practice can largely be considered as ecosystem reconstruction — the reestablishment of the capability of the land to capture and retain fundamental resources. In restoration planning, it is imperative that goals, objectives, and success criteria are clearly established to allow the restoration to be undertaken in a systematic way, while realizing that these may require some modification later in light of the direction of the restoration succession. The direct impacts of mining disturbance to land surfaces are usually severe with the destruction of natural ecosystems, either through the removal of all previous soils, plants, and animals or their burial beneath waste disposal facilities. Other indirect or multiplier effects can occur through the fragmentation of the original natural ecosystems and the alteration of surface and groundwater drainage patterns. There is also a probability of recurrence of impacts after mining (even after site reclamation) where mining wastes are regarded as secondary ore bodies, and old spoil heaps and tailings dams are

reworked for metals and gangue minerals. The accident occurred in 2000 at the Aural gold and silver producing plant at Baia Mare in Romania clearly showed the environmental consequences of reprocessing wastes activities when 50–100 t of cyanide were released into the Danube river system. The cyanide plume travelled to the Black Sea some 2000 km from the source of the spill, causing mortality of river biota.

The topics that we would like to address are: • National and European policies favouring urban regeneration: economic, social and environmental aspects; • Sustainable development as response to the overall aim of the EU Sustainable Development Strategy which aims to identify and develop actions to enable the EU to achieve a continuous long-term improvement of quality of life through the creation of sustainable communities able to manage and use resources efficiently, able to tap the ecological and social innovation potential of the economy and in the end able to ensure prosperity, environmental protection and social cohesion; • Conservation and management of the existing natural resources and the development of new approaches for secondary resources processing (industrial wastes , housekeeper wastes, DEEE) • The importance of energy efficiency, sustainable & ecological transports, sustainable consumption & production and public health in urban regeneration projects as a response to challenges imposed by EU’s objective regarding climate change and clean energy; • The role of Public private partnerships in urban regeneration; • Urban live ability - Polycentrism as a key to revitalizing local sub-centers and renewed urban environment through high quality mixed neighborhoods: revitalizing housing, open spaces and industrial sites; • Urban creativity - Multiculturalism: how to increase community capacity and enhance social integration through the promotion of multi-cultural activities, Support to the entrepreneurial initiatives in the sectors of tourism and fruition of cultural goods, Valorization of social and cultural diversity, Development of forms of mining tourism; • Urban innovation - A dynamic economy supporting the long term prosperity of the many communities, Understand the interrelatedness of the economic, physical, social, funding and delivery issues in a sustainable housing market, Conversion from a mono- economy based on mining, to a multi-lateral economy • The role of active and innovating neighbourhoods in urban regeneration by effective involvement of local actors/stakeholders in Community Regeneration projects - strengthening the capacity for local actors to develop and generate good practice solutions to key issues linked to the overarching theme of community regeneration. Participation at local level is one of the core component of the methodology for developing urban sustainable development; • The role of education, innovation and research from the urban regeneration perspective; • Reducing Environment and Security Risks from Mining in the Tisza River Basin by Management of mining, quarrying and ore-processing waste, including the assessment of risks linked to mining waste, Improvement of management of waste, Prevention and Remediation Issues in Non-Ferrous Mining. Improving regional cooperation for risk management from pollution hotspots as well as the trans-boundary management of shared natural resources; • The role of public finance from the urban regeneration perspective; • The contribution of the regional policy of the EU to the urban regeneration process.

The political objective to be pursued The political objective is to raise awareness on the importance of the participation of cities and regions in the in meeting the environment targets at the EU and national level by means of policies and sustainable urban regeneration projects. Baia Mare can provide a European model for a city trying to reconvert itself and to redirect its economy to other domains and field, such as natural resources conservation and management by improved processes, use and development of industrial recycling, use and improvement of the existing infrastructure and of education for regeneration and development purposes

The strategic relevance of the activity Urban regeneration and particularly the environmental aspects of regeneration projects among the priorities of the EU: • The implementation of the Leipzig charter on Susta inable European cities , precisely the need to improve the energy efficiency; • The Goteborg agenda of the EU and the necessity to move towards sustainable development and to reinforcement of the protection of the environment; Baia Mare is one of pioneers among the members of the Romanian Municipalities Association in developing and improving the Urban Network in Romania, as well as a development pole for the North-West Development Region, Carpathian Euro Region, Tisza River Basin (neighbourhood and good relations with Hungary and Ukraine).

The added value of such an approach • The added value consists in the in the first place in the relevance of the development to the political priorities of the EU in promoting sustainable urban development, energy efficiency growth and job creation in cities and regions . Secondly, the issue of urban regeneration and especially the environmental aspect of such projects are of a particular importance for cities in actions for mitigation and adaptation to climate change . • The development is of strategic relevance in our view and could represent an added value for the EU’s opinions related to the energy package and the white paper on climate change , by providing examples on how EU policies are implemented in concrete urban regeneration projects. • The development will encourage the promotion best practices examples : local initiatives of public policies, programs and projects of urban regeneration and also to reflect on new measures taken at local level in connection with the reviewed European strategy for sustainable development approved by the European Council in June 2006.

Sources http://baiamarecity.ro

Barnsley – United Kingdom

Elaine Ogden Public Health - Barnsley Metropolitan Borough Council / Barnsley Primary Care Trust 15 th of July 2008

General socio-economic context: current situation and main issues related to health

Barnsley is an area both of diversity and challenge. The west of the borough is rural and the east is urban and industrial. It covers an area of 32,863 hectares, 68% is green belt and 9% is National Park land.

Population The population of Barnsley is 224,600 of which 53,500 (24%) are aged 0-19, 134,000 (60%) are aged 16 -64 and 37,100 (17%) are aged 65+ (Office of National Statistics 2008 estimates). Of the 224,600 population in Barnsley 114,900 (51%) are female and 109,700 (49%) are male. The population of Barnsley is projected to increase by 9.0% between 2007 and 2029, slightly lower than the national projection of 10.8%. There is a wide variation in the projections for age groups:

• Pre-school (0-4) ages are projected to remain consistent; nationally it is predicted to increase slightly. • Primary school age populations (5-9) are projected to increase slightly in Barnsley and nationally. • Secondary school age populations (10-19) are projected to fall in Barnsley mirroring the national projections. • The working age population ages are projected to remain consistent; nationally it is predicted to increase slightly. • The most significant increase is projected for the population of retirement age (65+). There is a 56.3% predicted increase in Barnsley, slightly higher than the national average of 50.6%, but the increase in the (75+) population is higher at 66.1%, again slightly higher than the national average of 60.0%.

Barnsley will see its population age in line with the rest of the country. The percentage of the population over 65 will increase from 15% of the population to 23% by 2029. People over the age of 65 are far more likely to require health and social care support services and this projected growth in both numbers and percentage terms will require planning for.

In Barnsley it is estimated that in 2005, 96.7% of the population are ‘White British’ compared with 84.7% of the population of England as a whole.

In Barnsley there are approximately 800 migrant workers. The largest groups are from Poland, the Republic of Latvia, India and the Czech Republic. Not all employers or workers are aware of the legislation and therefore many workers may not be registered. Indeed, many casual workers may not work for a single employer for longer than a month. Migrant workers in Barnsley are likely to experience greater deprivation than the rest of the population. They are likely to have poorer access to and knowledge of local services than others. Only 39% are registered with a doctor and 9% with a dentist.

Socio-Economic • Barnsley has higher rates of claimants for Attendance Allowance, Disability Living Allowance, Incapacity Benefit / Severe Disablement Allowance, Income Support and Job Seekers Allowance than the England average. • Data for 2006 shows that 12.9% of the working age population in Barnsley are claiming Incapacity Benefit/Severe Disablement Allowance compared to 7% in England • 28.3% of Barnsley children and young people live in households where at least one adult is claiming a ‘working age’ benefit. • 23.9% of all dependant children are living in poverty in Barnsley, higher than the England average of 19.7%. 1 in 4 (26.4%) of children aged 0 to 4 years are living in poverty in Barnsley, again this is higher than the England average of 21.3%. • Barnsley’s unemployment rate is 5.8%, the national average is 5.4%. • Barnsley has a median household income of £24,570 compared to the national average £32,342. • 45% of migrant workers reported being paid at £5.05 per hour( statutory minimum wage at the time of survey). 41% reported being paid a higher rate. • Average Barnsley wage for men is £10.41 per hour and £8.65 per hour for women (source NOMIS 2006) • 32.2% of households across Barnsley had no access to a car or van (5.4% lower than England average). • Barnsley is ranked 43 rd most deprived local authority by IMD(2007). It was 28th according to IMD(2004). This change is evidence that there have been some positive changes in the last three years in Barnsley, although the borough is still disadvantaged. • 64.2 % of houses are owned by the occupier (68.7% nationally), 23.6% are rented from the Council (13.2% nationally), 2.1% are rented from a Housing Association or registered social landlord (6.1% nationally) and 10.1 % are private rented or rent free (12.0% nationally).

Institutional Framework

There are two lead statutory agencies that provide a range of services for the local population :

Barnsley Metropolitan Borough Council is the local authority and provides services such as education, social services (provided in partnership with the PCT), culture/sport/tourism, economic regeneration, planning and transportation, highway maintenance, parks and open spaces, waste management and refuse collection, social housing etc.

Barnsley Primary Care Trust is part of the National Health Service and is responsible for commissioning services to meet the health needs of the local population. It commissions primary care services such as GP’s, dentists, health visitors etc, secondary care services within hospitals and specialist care services.

These two statutory agencies also work in partnership to deliver health and social care for vulnerable people and people with disabilities.

The Local Strategic Partnership (LSP) brings together the top people from the Police , PCT , Barnsley College , Local Authority , Chamber , Barnsley Black and Ethnic Minority I nitiative,

Learning and Skills Council , Yorkshire Forward (Managing Authority), Job Centre Plus , Government Office(Yorkshire and the Humber) and the Voluntary & Community sector to tackle problems that face Barnsley.

The LSP has developed the Barnsley Sustainable Community Strategy (SCS) 2008-2020, which sets out the long-term vision and ambitions for the Borough over the next 12 years. The Local Area Agreement (LAA) 2008-2011 is a 3 year delivery plan which details outcomes, actions and performance targets that will deliver short to medium term improvement priorities and contribute to achieving the SCS vision and ambitions over the long term. The LAA has been approved by Central Government.

Key Health Information

• Life expectancy in Barnsley is improving but the gap between Barnsley and England is widening • Smoking prevalence remains high in the borough, around 50,000 adults are smokers which is over 25% of the population. • 1 in 4 new mothers were smokers at the time of delivery. • 19.4% of the population consuming 5 or more portions of fruit and vegetables daily, the lowest figure in the Yorkshire and the Humber Region and lower than the national average of 26.3%. • It is estimated 25.8% of adults in Barnsley are obese, significantly higher than the national average of 23.6%. • A third of Barnsley children are overweight or obese. • Alcohol related mortality for females, alcohol related hospital admissions for under 18s and adult males are significantly worse than the England average. • 19% of the Barnsley adult population take part regularly in sport and active recreation; this is lower than the Yorkshire and the Humber figure of 20.1% and the national figure of 21% • New diagnoses of chlamydia, gonorrhoea, genital warts and herpes have increased in Barnsley.

Main Issues related to health

Barnsley has the eighth highest risk of obesity in the country, reflecting the Borough’s high level of deprivation and culture of unhealthy eating and physical inactivity. To halt the rising levels of obesity we need to address the obesogenic environment by improving the infrastructure for safe walking and cycling routes and develop active travel and transport plans. At the same time we need to change individual behaviour so that people are eating a healthier diet and increasing their levels of physical activity. To close the gap in life expectancy we need to focus on reducing coronary heart disease and reduce the prevalence of smoking.

Theme 1: Health Impact Assessment (HIA) and the use of urban health indicators

We have limited experience of carrying out HIA before a policy, programme, product or service has been implemented. One example was involvement in a sub-regional HIA of a proposal to

widen the M1 motorway from 3 lanes to 4 lanes. There are plans to carry out a HIA on the South Yorkshire Transport Plan. We are also in the process of placing Public Health ‘experts’ within the planning and transportation departments of the Local Authority so that they can carry out HIA on new planning applications and developments. Most of our HIA’s have taken a retrospective view by evaluating the impact programmes have had on improving health outcomes after they have been implemented. Examples of these include: Healthy Living Barnsley Programme – a Big Lottery funded programme, delivered through third sector organisations, to improve health outcomes in our most deprived communities. Fit for the Future – A 3 year review – Fit for the Future is Barnsley’s cross-sector programme for improving health and reducing health inequalities. It is a long-term programme but this review assessed progress after the first 3 years.

In Barnsley we have a range of indicators that are used assess the city as a whole. Some of these indicators refer to a medical approach to health such as mortality rates from coronary heart disease and cancer but many are more oriented towards the quality of life.

Nationally there are 198 National Indicators that each Local Authority, working alone or in partnership with other agencies and organisations, must collect and report to Central Government. The list of 198 indicators is attached at Appendix A. From the list of 198 indicators each Local Authority area must select up to 35 (along with 16 statutory education targets) which are identified as priority issues for improvement locally. Challenging 3 year improvement targets are then negotiated through a Local Area Agreement. Barnsley’s Local Area Agreement 2008-2011 has recently been agreed and signed by Government Ministers. The improvement targets agreed for Barnsley are shown in bold at Appendix A.

Barnsley Primary Care Trust also has a number of health indicators which it must collect and report to the Department of Health. This set of indicators is known as ‘Vital Signs’ and is attached at Appendix B.

A number of indicators, both from the National dataset and from Vital Signs, along with other statistical information, are used both at a regional and local level to help us compare Barnsley with other cities. The Barnsley Health Profile (Appendix C) is an example of this.

In South Yorkshire there is an information project that groups small areas together with similar profiles. This allows us to look at both the similarities and the differences and to share information about what is working to improve things in those areas.

In Barnsley we also have a ‘Local Neighbourhood Statistics’ project. This provides information at a neighbourhood level and is particularly useful for Elected Members.

We already use a range of urban health indicators to support our work. We are keen to learn from other areas and to help identify any additional indicators that would enhance these. These indicators support us to: • identify any potential problems (issue-based or geographical) • target resources effectively • monitor the impact of any intervention/investment

We are keen to make more systematic use of HIA. Barnsley is undergoing a transformational change (Remaking Barnsley) to support its economic regeneration. This is linked with a programme of investment in new Advanced Learning Centres to replace old school buildings

(Remaking Learning). This provides us with a window of opportunity to make sure that this large scale re-development enhances the quality of life and provides an health improving environment.

Theme 2: Policies and actions for an active and healthy ageing

The Adults and Communities Wellbeing Partnership is the delivery partnership of One Barnsley (LSP – see Institutional Framework), responsible for adult health and social care and the wider promotion of adult wellbeing. The local vision for adult health, independence and well-being is set out in the document entitled Every Adult Matters (EAM). Its 3 themes are: • Recognising people are in control of their own health and care • Enabling and supporting independence and wellbeing • Rapid and convenient access to high quality, cost-effective services

Self directed support is central to the vision of EAM and Barnsley is making great strides towards implementing self directed support as the mainstream approach to meeting the needs of local people. People themselves will decide how and when they are supported rather than professionals telling them what support they will get.

An Older People’s Wellbeing Strategy is currently being developed which will focus on actions to maintain good health and wellbeing into older age. The strategy is being developed in consultation with older people who are represented on the Older People’s Board.

There has been a problem in Barnsley with the number of older people who were falling and suffering fractures and other injuries as a result. To address this problem a falls service has been introduced over the past 3 years. A vast amount of work has been done with services such as intermediate care, district nursing, the acute hospital, the independent sector, Local Authority’s central call service and the ambulance service to develop a co-ordinated approach to the prevention of falls by the introduction of a falls risk assessment tool, use of assistive technologies and the development of care pathways to enable services to link and inter-refer. As a result of this work the number of admissions into hospital as a result of a fall as reduced by 20%. Barnsley Council provides a Central Call Social Care Alarm Service. The service operates 24/7 365 days a year offering both monitoring and response support. The service currently supports 5,000 vulnerable service users with Lifelines. 298 people also benefiting from additional telecare support such as smoke detectors, bed monitors, falls detectors, bogus caller buttons and property exit sensors.

Home care services operate across Barnsley providing 4,500 hours of care to 650 older people allowing them to remain in their own homes.

Age Concern is an active charitable organisation that provides a number of services and activities specifically for older people. Their aim is to support older people to remain active, healthy and independent. Some of the services they provide include: • Home Safety and Handy Person Scheme – a free home safety check for older people. A handy person will carry out any safety-related pieces of work for the cost of the materials only. • Hospital Support and After Care service – based in the accident and emergency department at the hospital to provide practical support to ensure the safe return home of older people attending.

• The Agewell Service Model – providing the range of services offered by the town centre office in outlying areas. • Grocery shopping home delivery service as well as lunh clubs, drop-ins and leisure and learning classes. • Advice and information services • Advocacy service • Befriending service

A week long Older People’s Festival was held in October 2007. The aims of the week were to provide support and information about healthy choices, to challenge myths about older people and to bring together information about activities happening across Barnsley. The feedback from the festival was very positive and this will now be an annual event.

Although a considerable amount of work is taking place more work needs to be done to support the general ageing population to have a healthier lifestyle which will ensure they enjoy a good quality of life and independence in their older years. Focus needs to be given to: • Increasing physical activity • Improving diet and nutrition • Reducing levels of obesity • Reducing smoking • Improving mental wellbeing • Preventing cognitive decline • Addressing issues of loneliness

Theme 3: Healthy Places and Healthy Environment

One of the major challenges facing Barnsley is the increasing levels of obesity. Barnsley has the eighth highest risk of obesity in the country, reflecting the high level of deprivation and culture of unhealthy eating and physical inactivity. The long term challenge of improving Barnsley’s health requires a fundamental attitudinal shift amongst the local population supported by significant infrastructure changes. The infrastructure changes required include : • Improving the obesogenic environment through effective planning controls during the redevelopment of the city • Health impact assessment of future planning applications • Effective transport planning which provides cycling networks, park and ride schemes etc. • Safe routes to schools and within communities • Cleaner, safer and greener parks and open spaces that encourage people to be more physically active • Development of allotments and community gardens for growing food

Addressing these issues also contribute to positive mental wellbeing with people feeling safer and having a more positive attitude to their community.

There are a number of planned projects and programmes that will help us to tackle the issues identified above. These include: • Strengthening connections between planning, transport and health supported by multi-disciplinary training and new Public Health posts based in Planning. This will develop the health policy base to our Core Strategy for Spatial Planning and will enable

developments to be “health checked” with an emphasis on access to healthier food and active travel. • Developing the infrastructure for safe walking and cycling routes to 5 advanced learning centres (ALCs) being built in Barnsley as part of the Building Schools for the Future programme – a once in a generation opportunity. This will be complemented by measures to change the culture to encourage their uptake by children and adults and discourage car use. • Create more opportunities for all to take part in sport and active recreation . • Use social marketing to promote healthy eating and physical activity, tailored to parents of children in deprived communities. • Expand community health development in partnership with Barnsley’s acclaimed Fit for the Future Programme . Areas of development will include: increasing use of allotments; improving access to affordable food in convenience stores in deprived/rural areas; extending cook and eat sessions in deprived neighbourhoods and expanding weight management programmes for adults and Fit Kids Club for obese children. • Develop our work as a national pilot for workforce development , promoting healthy eating and physical activity, initially in the public sector workforce and extending it to employers across Barnsley.

The main challenge facing us is being able to implement these programmes is the lack of financial resources. We are applying for additional funding wherever possible to allow us to implement these plans. It is anticipated that this Building Healthy Communities thematic network will help to influence the use of Structural Funds for these areas of work.

There are a number of ‘unhealthy’ areas that could be selected for this purpose. One of these areas is Athersley/New Lodge.

Athersley/New Lodge has a population of approximately 10,000 people of which 99.4% are white. It is one of the most deprived areas in Barnsley with high unemployment, low car ownership and high levels of child poverty. It has the highest proportion of residents with no qualifications, affecting 53% of those aged 16 – 74 years. It is dominated by 3 large social housing estates.

In the 2001 census, 27.1% of the population reported themselves as having a long-term illness, health problem or disability that limited their daily activities or the work that they could do. The average male life expectancy (2003-2005) was 72.1 years (76.9 years nationally) and the average female life expectancy was 79.3 years (81.8 nationally). In 2006, 28.1% of children measured at age 4-5 years and 10-11 years were overweight or obese. Pregnancies in 15 – 17 year olds is almost twice the Barnsley average.

A survey of 500 households carried out in 2006 highlighted a number of issues : • high levels of anti-social behaviour including youths gathering around shops, pubs, alleyways etc, • lack of police walking the beat, • the need for better street lighting, • environmental improvements needed to stop vehicle crime incidents in certain areas of New Lodge.

A neighbourhood management approach is now underway in this area to involve local residents in the plans and actions to improve the area. A master plan to improve housing in the area has been developed which will be implemented over a 10 year period. Estate Ambassadors have been employed who work alongside local people encouraging residents of all ages to get

involved in setting up and running activities and events where people can start to take some civic responsibility for their neighbourhood. A community development and health worker has been employed to work with local residents, groups etc. on issues relating specifically to health. There are now more local opportunities to take part in physical activity sessions, cook and eat skills training, relaxation classes etc.

Theme 4: Use of Structural Funds in designing actions to develop "health gains"

The ERDF operates as a Yorkshire and Humber programme over the seven years 2007-2013, with £180m ring-fenced for South Yorkshire. The spend profile in South Yorkshire is heavily concentrated in the early years. Overall governance of the programme rests with the Yorkshire and Humber Programme Monitoring Committee (PMC). A South Yorkshire Programme Management Board (PMB) plays a key role in overseeing the programme in the sub-region. Yorkshire Forward (YF) manages the programme on behalf of the UK Government. The Programme is heavily focused on making the region’s economy more knowledge based, operating through five Priorities:

P1: Promoting innovation and R&D P2: Supporting and stimulating successful enterprise P3: Sustainable communities P4: Economic infrastructure for a knowledge economy P5: Technical assistance

Because of the late start to the programme, delivery will be organised in two phases: a short transitional round in the first quarter of 2008, followed by more structured long term arrangements. Yorkshire Forward is still developing the Priority Prospectuses for the second stage, and intends to do so in collaboration with a series of “expert” groups. Fully developed proposals from Barnsley cannot be determined until these Priority Prospectuses are finalised.

The majority of the ESF Programme in South Yorkshire will be co-financed by the Learning Skills Council (LSC) or Department for Work and Pensions (DWP). The exceptions are activity to support young people aged 14-16 and reduce the NEET (not in education, employment or training) percentage.

LSC Adult Tenders Round 1 : The LSC will be contracting £100 million in total from this round. There is the potential for 39 contracts regionally ad the LSC are progressing 30. Some activity is to be re-tendered or the activity re-combined for contracting in round 2.

Job Centre Plus Tenders : Job Centre Plus projects began to deliver from 23rd June. There are no specific health related activities, other than Incapacity Benefit claimants being a target group.

LSC Tender round 2 : The LSC announced invitations on 14 th April, with a closing date of 26 May. Organisations wishing to tender need to complete both a national and regional invitation to tender for each region in which they are seeking to deliver the programme. The proposed areas of regional work are: a. Regional: Train to Gain b. Regional: Apprenticeships c. Regional: Community Grants Co-ordinating body There will be no separate tender for volunteering activity in South Yorkshire. LSC contracts are awaiting signatures, but should start in September.

Barnsley was successful in its tender for the management of 16+ NEETS activity. This was a proposal led by Barnsley Council on behalf of the local NEETS strategy group partnership. The NEETS Strategy group will convene a subgroup to draft specifications and commission activities, planned to commence in September.

An expression of interest has been submitted from Barnsley for ESF Technical Assistance.

We can find only very limited evidence of the use of Structural Funds that are directly or indirectly linked to health and quality of life, in that some Healthy Living projects obtained match funding from Priority 4 ERDF. There have been a number of other funding programmes over the last 10 years that we have accessed to develop actions/projects/programmes related to health and quality of life. This have included: Health Action Zone – additional government funding to areas with the poorest health outcomes. Barnsley was part of the South Yorkshire Coalfields HAZ. Approximately £880K per year was allocated to Barnsley to introduce a range of health improving interventions in the most deprived communities. A particular focus was given to heart health. Neighbourhood Renewal Fund – additional funding allocated to Local Authorities by Central Government to target action in the most deprived neighbourhoods. The funding had a number of ‘floor targets’ attached to it which areas were expected to meet using the funds. One of the floor targets was about reducing the gap in life expectancy between the poorest areas and the national average. Barnsley’s Fit for the Future programme was allocated approximately £400K - £500K per year from 2003- 2008 to implement health interventions. Choosing Health – Additional mainstream resources given to Primary Care Trusts in areas with the most health deprived communities. It was intended that these resources be allocated to preventative interventions rather than treatment services. Barnsley received £2m per year. Big Lottery Funds – a range of funds provided by the proceeds of the UK’s National Lottery. Different programmes of funding are available for individual projects to bid into. Barnsley has recently been awarded £300K per year for 3 years as part of a successful regional bid to the Wellbeing Programme.

The ERDF and ESF programmes established for Yorkshire and the Humber region focus strongly on developing the economy. The priorities outlined in the Operational Programmes make no reference to the impact that poor health has on the economic competitiveness and employment rates. It is therefore not possible to meet the criteria used for allocating the funds with any programmes aimed at tackling health and quality of life.

Sources Barnsley Joint Strategic Needs Assessment Barnsley Sustainable Community Strategy 2008-2020 Barnsley Local Area Agreement 2008-2011 Joint Strategic Needs Assessment Yorkshire and The Humber Regional Competitiveness and Employment Programme – Operational programme 2007-2013 Report to Barnsley Central Investment Plan Group on ERDF Programme, February 2008 Report to European Funds Task Group, April 2008

Belfast – United Kingdom

Adele Keys Belfast City Council 27 th June 2008

General socio-economic context: current situation and main issues related to health

Our health is largely determined by our living conditions: income, housing, education, environment, social support and wider social and economic conditions. The figure below illustrates the main determinants of health and how they work together. It shows that the responsibility for health lies with society as a whole, and that agencies developing policy or delivering services have a particular responsibility to make a difference to people’s health and wellbeing.

Poverty is the most important risk factor for poor health. Education is another related factor as people with few educational qualifications are more likely to be unemployed or in a poorly paid job. They may also have difficulties accessing information and making use of it. The result is often relatively poor living conditions and few opportunities to change them. On the other hand, people with a good income can buy a decent house in a decent environment. They can also afford a healthier diet, and often have better opportunities to access and follow health information and advice, for example regarding health lifestyles. The Belfast City Council area is 115km². Approximately 260, 000 of the 1.5 million people living in Northern Ireland live in Belfast, this is approximately 15% of the total Northern Ireland population. Belfast has a higher proportion of young people and elderly people than the rest of Northern Ireland with one fifth of the population under 16 years and one fifth aged 60 and above. According to Census 2001 just over 1% of the Northern Ireland population are from an ethnic minority group; however, this is a growing population and 20% of all migrants in Northern Ireland live in Belfast. The 2001 House Condition Survey showed a higher proportion of unfit homes in Belfast as unfit (5.9% compared to a NI level of 4.9%). Belfast remains a divided society with 42 identified interfaces (BIP 2008).

Approximately 20% of people living in Belfast have degree or higher level education. There are a higher proportion of school leavers with no formal qualifications in Belfast than elsewhere in Northern Ireland. 45% of Belfast population are economically inactive. Of the 6% who are unemployed almost half are long term unemployed. In August 2006, 22 ,463 people (13.5% of the working age population) were in receipt of Incapacity Benefit in Belfast. The total number of jobs in Belfast is 192,293. Half of the people in Belfast live in the most deprived areas of Northern Ireland. Belfast has 9 of the 10 most deprived wards out of Northern Ireland’s 582 wards. One quarter of people in Belfast have a limiting long-term illness, health problem or disability in the most deprived wards, compared to 10% or less in the least deprived wards. However, 65% of people in Belfast stated that their health was good. Life expectancy in Belfast - in some of the most deprived wards less than 70 for men and 75 for women – the average is 73.4years fro men and 79.3 for women. Large concentrations of multiple deprivation exist in the north and the west of the city however pockets of deprivation exist all across the city. Belfast has a poor record in terms of health compared to the rest of Northern Ireland. The death rate in the city from heart disease, strokes and cancer is one of the highest in Europe. The worst 9 wards in Northern Ireland in terms of health deprivation are in Belfast. There are wide pockets of health inequalities across the city and the gap in life expectancy is not reducing between the most affluent areas and the most deprived. DHSSPS (2007) research indicates that although there have been some relative improvements there is a continuing health gap between the most deprived areas and NI overall. Those who live in the 20% most deprived wards have a poorer life expectancy, higher death rates, higher admission rates to hospitals, more infant deaths and more suicides compared to Northern Ireland as a whole. The George Best City Airport and the Belfast International Airport are located 2 and 20 miles respectively from Belfast city centre. The airports serve over 40 scheduled destinations with domestic, European and transatlantic services. The number of scheduled destinations continues to grow. In 2006 the Port of Belfast handled 17.5 million tonnes of goods and carried over 1.2 million passengers making it the busiest port in Ireland. 6.8 million people (a 6% rise on 2005) visited Belfast in 2006 injecting an estimated £32 4 million into the local economy supporting nearly 18,000 jobs. 23 cruise ships docked in Belfast in 2006, up from 16 in 2005. 30 cruise ships will have docked in the city by the end of 2007. In 2006 Belfast was described in the Lonely Planet Guide as a “boom town” and one of the top ten cities “on the rise”.

Theme 1: Health Impact Assessment (HIA) and the use of urban health indicators

In Belfast, HIA is strongly endorsed in the public health strategy Investing for Health although it is not a legal requirement. Belfast Healthy Cities have pioneered several HIA’s in Northern Ireland. These include assessments on: the proposed introduction of water charging, the proposed redevelopment of the North-East and North-West quarters of Belfast City centre: the regeneration Strategy of the Lower Shankill, the proposal for the Connswater Community Greenway, Response to Belfast City Centre North West Quarter Part II, Baseline Regeneration Issues Report January 2007, Government proposals to reform liquor licensing in Northern Ireland, draft Eastern Health and Social Services Board Green Travel Plan, Belfast Air Quality Action Plan, DSD Masterplans, Community Health Impact Assessment Pilot Project Ards and Ballybeen. Belfast Healthy Cities is one of a limited number of organisations in Northern Ireland to have carried out an HIA. They were also the first in the region to pilot a community led approach in the Community Health Impact Assessment project. In developing capacity, Belfast Healthy Cities has worked closely with Erica Ison, specialist HIA practitioner, affiliated to the Public Health Unit, Oxford. She is now also the expert advisor to WHO on HIA.

The current HIA programme at Belfast Healthy Cities aims to integrate health impact assessment into organisations’ planning and decision making processes. In particular, the aim is to integrate HIA into non-health policies, to provide a mechanism for considering health within these. Policies in Northern Ireland currently undergo a range of impact assessments, but health is not an explicit consideration within many of these. The programme focuses on training staff in key organisations on HIA to develop a basic understanding of the concept. Selected staff have also participated in HIA’s to provide them with practical experience in conducting HIA’s. The plan is to provide further training, to enable them to become trainers within their organisations. Key partner organisations for training have included EHSSB, Belfast City Council, Northern Ireland Housing Executive, the Belfast Metropolitan Area Plan team and (prior to April 2007) the two Health and Social Services Trusts in the city. Further training is planned for the latter part of 2008. The second major element of the programme is to carry out HIA’s. Since there is limited expertise in Northern Ireland in conducting HIA in practice, Belfast Healthy Cities will continue to conduct HIAs using external support where appropriate and build experience and expertise which can be shared in future. A number of HIA’s are planned for 2008. Proposals to be assessed will be identified on a continuous basis and HIAs to be carried out will be agreed with the developers of proposals. A final element of the programme is to develop an online evidence base for HIA, which organisations can use for their own impact assessments. Belfast is the lead city for the sub network on HIA. The HIA sub network is co-chaired by Belfast Healthy Cities and the Institute of Public Health in Ireland, which develops HIA training programmes on an all-island basis. The network has seven member cities in addition to Belfast: Bologna (Italy), Brighton and Hove (UK), Copenhagen (Denmark), Geneva (Switzerland), Helsingborg (Sweden), Ljubljana (Slovenia), Turin (Italy), Turku (Finland) and Yalova (Turkey). Erica Ison, specialist HIA practitioner, affiliated to the Public Health Resource Unit, Oxford, is the WHO expert advisor to the group. The sub network has concentrated on arranging training events across the European Network, particularly for HIA beginners. More recently a HIA Practice Development workshop was held for cities that have gained some experience in conducting HIAs. To date, training events have been arranged in Paris (France), Lodz (Poland) and Turku. The most recent sub network meeting was held in Belfast in May 2007 and included training on peer review. The HIA sub network is also exploring ways of making links with the Healthy Urban Planning Sub network and the Healthy Ageing Subnetwork to develop ways of cross linking work on the core themes. Belfast City Council and Belfast healthy Cities are working to design a HIA tool that will assist staff to optimise the health gain that it can obtain from Council Strategies, policies, plans, programmes and projects (proposals). The desktop tool can be used during the design and development of any proposal, by single officers or as a team. It is anticipated that this tool will be available by January 2009.

The Investing for health (IfH) strategy was the first major interdepartmental strategy in Northern Ireland which aimed to tackle health inequalities by focusing on the wider determinants of health. The strategy sets a number of targets through which it could be measured. Belfast Healthy Cities led the development of health and wellbeing indicators on behalf of the Eastern health and Social Services Board (EHSBB). These indicators are designed to monitor progress against the Investing for Health goals and objectives within the EHSSB (Belfast) area. All Government departments and other sectors have a role implementing the IfH strategy due to the diversity of issues covered. A copy of the EHSSB Investing for health Indicators has been attached. Belfast Healthy Cities healthy urban planning programme aims to integrate health considerations into planning processes, programmes and projects and to gain the necessary capacity and political and institutional commitment to achieve this goal.

Healthy urban planning objectives The three objectives as defined by WHO are to: raise awareness and create a common understanding of the concept of healthy urban planning and all that it implies as key to changing practice within the city gain local practical experience from the application of healthy urban planning principles and approaches work towards mainstreaming healthy urban planning in the city and to propose institutional solutions for making healthy urban practices mainstreamed in the city. Within the area of healthy urban planning, WHO have prioritised four areas: Transport; Ageing; Obesity and Physical Activity and Neighbourhoods.

What is Healthy Urban Planning? Healthy urban planning means planning that promotes health and well being and has much in common with the principles of sustainable development. It means putting people back ‘at the heart’ of planning. The idea that planning and health are linked is not new. In many cities town planning originated early in the twentieth century as a result of concerns about the health and housing of citizens. The physical environment, which is shaped by planning decisions, can facilitate or deter a healthy lifestyle – people’s ability to walk; cycle or play in the open air is affected by the emphasis on quality and safety of the environment for pedestrians. Planning can act to enhance or destroy social networks and urban regeneration can cultivate opportunities for a rich community life. The sustaining of local facilitates and networks depends in part on the long term strategies for transport, housing and economic development. Healthy urban planning also implies a need to place values such as equity and collaboration – including intersectoral cooperation and community participation – in planning decisions. All of these are key themes in the World Health Organisation’s policy Health for All, which the Healthy Cities movement is based on.

Raising awareness & understanding Through the healthy urban planning programme we have played a major role in helping develop with planners and health professionals a greater understanding of how urban planning impacts on health. Belfast healthy Cities have helped to play a strategic role, by ensuring that attention has remained focused on health issues and as a result has supported policy makers in such areas. Through the work of the WHO Healthy Cities Action group in Phase III (1998-2002), where Belfast was represented by BMAP (Belfast Metropolitan Area Plan) we helped promote a greater understanding of the concept of healthy urban planning. This work also provided information to planners and health professionals on the interconnections between health and planning. The Regional Development Strategy for Northern Ireland recognises the key relationship between the environment and health and contains a strategic planning guideline to create healthier living environments and to support healthy lifestyles and the promotion of a healthy environment was also highlighted in the BMAP. Through the City Health Development Plan process, Belfast healthy Cities brought together a number of professionals from different backgrounds in working groups to assist in the development of a more integrated planning approach. As part of the programme to increase understanding on healthy urban planning, Quality of Life Matrix was produced, a tool to support planners to assess quality of life issues within Area Plans. In 2007, the Polytechnic of Milan translated the Matrix to Italian and adapted it for local use. Healthy Urban Planning Programme. A healthy Urban Planning (HUP) Working Group has also been established.

The role of HIA in Healthy Urban Planning The approach to the healthy urban planning programme in is to explore health impact assessment as a tool to promote healthy urban planning. The key aim is to examine how health impact assessment might be integrated into existing impact assessments in spatial planning policies, which currently are not routinely assessed for their potential impact on health. The programme consists of several elements.

HIA Training An initial two day training session was held in February 2006 to introduce HIA to planners as well as other public sector professionals. The course was facilitated by Erica Ison, specialist HIA practitioner, affiliated to the Public Health Resource Unit, Oxford.

Healthy Urban Planning seminar A half day seminar was held in Autumn 2006 to explore how the city of Belfast can meet the WHO healthy urban planning objectives. Four workshops on the priority themes of transport; ageing; physical activity and neighbourhoods identified how each can be taken forward. The event attracted around 50 people including planners, local government representatives and health professionals. A working group was established to look at ways of taking forward actions identified at the seminar.

Queens University Undergraduate ‘Healthy Urban Planning’ module A module on healthy urban planning is included in the undergraduate programmes for the School of Planning, Architecture and Civil Engineering and the School of Medicine at Queen's University of Belfast from the academic year 2007-08, following a successful pilot in 2007. The module has been developed jointly by the Centre of Excellence in Interprofessional Education at QUB, Belfast Healthy Cities and the Eastern Health and Social Services Board. The aim of the module is to raise awareness of the links between planning and health and make students familiar with health impact assessment. It has been designed to be interprofessional, to promote personal links between future planners and health professionals and improve intersectoral understanding of the issues involved. In total 18 second year students from the School of Planning, Architecture and Civil Engineering and the School of Medicine took part in the pilot module on healthy urban planning at QUB in the spring term 2007. The module focused on investigating health impacts of the Westlink extension, in particular on air quality, transport and the local communities. The module culminated in May in a presentation to the Dr Paula Kilbane, Chief Executive of EHSSB and Dr David Stewart, Director of Public Health at EHSSB and Chair of Belfast Healthy Cities. The module has also generated interest from other universities who are interested in replicating it.

WHO Healthy Urban Planning Sub network The lead city for the healthy urban planning sub network is the city of Milan in Italy, and Belfast is one of 15 member cities. Belfast is represented in the Healthy Urban Planning Sub network by a senior planner form BMAP (Belfast Metropolitan Plan) team. Belfast was also involved in the predecessor to the sub network, the City Action Group on healthy urban planning which initiated work on the concept in 2001-2003. The action plan of this sub network focuses on training, introducing the concept of healthy urban planning to cities, developing tools and identifying areas on which principles can be applied. The Sub network has identified four areas for action: obesity and physical activity; transport; neighbourhoods and healthy ageing. The Polytechnic of Milan and Hugh Barton from the WHO Collaborating Centre for the Built Environment/University of West England are the expert advisors to the group.

City Stats

Belfast City Council is developing a city-wide neighbourhood intelligence system. Called ‘Belfast Citystats’ the system will provide the council and its partners with strategic information at neighbourhood level, including information on health. Belfast Citystats draws together over 200 geo-tagged datasets from a wide number of third party sources under a number of thematic realms. (The ‘Health’ realm currently has 30 datasets.) The system will contribute to the development of a local area working model within the council. It will provide the necessary strategic information to allow the council to identify difference in local issues and need and to respond appropriately. The initial product of Belfast Citystats will be 21 comprehensive neighbourhood sustainability profiles which are due in autumn 2008 .

Objectives - To integrate health impact assessment as a systematic framework in cities which enable decision makers to take account of peoples’ health and well-being during policy, programme or project developments. - Develop toolkit for HIA for Belfast - Pilot the use of the toolkit and identify mechanisms for mainstreaming the process - Evaluate the toolkit with a view to involving other statutory agencies - Develop strategic approach to HIA across agencies - To integrate health considerations into city urban planning processes, programmes and projects and to establish the necessary capacity and political and institutional commitment to achieve this goal. - Continue to monitor Investing for health indicators (DHSSPS and NINAS) - Produce a City Health Profile

Theme 2: Policies and actions for an active and healthy ageing

At the last Census day, 29 April 2001, the city of Belfast had a total of 277,391 residents. The Census counted in total 82,378 persons over 50 and 54,518 persons over 60. Proportionally people over 50 accounted for 29.6% of the population in Belfast, while people over 60 accounted for 19.65% of the population. A bigger proportion of the Belfast population is aged 60 or over compared to the Eastern Health and Social Services Board area (in which Belfast is a part of) and Northern Ireland as a whole. The population over 60 in Belfast is projected to stay static over the next decade while the populations over 80 and 85 are projected to grow. Within Northern Ireland there have been an increased number of strategies focusing on older people. Services for older people are proposed under the overall framework of the cross cutting strategy Ageing in an Inclusive Society (OFMDFM 2005), while the public health strategy Investing for Health provides an overall framework for addressing health through the wider determinants of health. Investing for Health (Northern Ireland Executive 2002) also provides a framework for working in partnership and with population groups to develop services for them.

Specific work in Belfast As an integral element of the Eastern Health Social Services Board’s Older People’s Health and Wellbeing strategy developed in 2006 , Belfast Healthy Cities also developed in partnership with a wide variety of sectors in the city, an intersectoral action plan called “Healthy Ageing InterAction (2006-2009)”. This process provided a unique opportunity to integrate with the Eastern Health and Social Services Board’s work on older people. The action plan was developed to encourage organisations to address key health determinants which have a major impact on older people’s health and quality of life. These determinants were identified by older people themselves. Actions were agreed under the following themes: community support networks; health promotion/ development; transport; home safety; housing; community safety and fuel poverty. Work is currently ongoing to deliver on actions within the InterAction plan at a city level.

Alongside the Interaction plan, in 2006 Belfast Healthy Cities developed a detailed profile of older people in Belfast. The aim of this profile was to raise awareness of older people’s social, health and living conditions; to identify any gaps in currently collected information, and to support organisations plan for older people. This profile provided a wide ranging overview of available statistics, covering topics from demography and health to housing and transport as well as community safety and access, participation and support. Belfast City Council established a cross party group in 2006 to consider issues associated with the health, safety and wellbeing of older people in the City identified 4 priority areas namely Advocacy, Interagency working, Improving Council Services and Citizenship. The Council also established in November 2007 a Council wide officer group looking at ways to improved council services for older citizens. The first senior citizens convention was held on 29 th May 2008, the purpose of which was to address advocacy and citizenship. The convention will become an annual event. The purpose of the day was to give older people access to decision makers, to give them a voice and to provide an opportunity for older people to influence the decisions that affect them. The Council has been working with the Belfast Seniors Forums, Engage With Age and Voluntary Services Bureau to ensure that older people have a strong voice in the city.

One of the key actions outlined in the Healthy Ageing InterAction plan was the establishment of a strategic multi agency group within each new Trust/ Council area that would develop collaborative approaches to addressing issues affecting older people; build capacity to strengthen engagement of older people and provide an effective voice within the setting of priorities and development of services. In Belfast a Strategic Intersectoral Healthy Ageing Partnership is currently being established to take this work forward.

The purpose of the partnership is to: Develop and agree an overall programme of work and success indicators with partners including the age sector, that facilitates a multi agency, integrated approach to the planning of services initially under the following four themes identified by stakeholders (including older people): Joined up information and advice Community Capacity building Combating Social Isolation Home support services/ Care and repair

Theme 3: Healthy Places and Healthy Environment

Belfast faces a number of challenges. Although there are a number of areas of affluence, much of Belfast faces the challenges of poverty and disadvantage. The poorest areas often face multiple problems – unemployment, low educational achievement, welfare dependency, high levels of drug and alcohol abuse, high levels of teenage parenthood, higher levels of crime etc. These are the areas which would be perceived as not being ‘healthy places’ or having a ‘healthy environment.

There are many initiatives and programmes over the years which have sought to address the above issues. The following are a selection:

Neighbourhood Renewal Strategy: This is a Government programme which seeks to tackle ‘the complex, multi-dimensional nature of deprivation in Northern Ireland’s most disadvantaged urban neighbourhoods.’ The goals of Neighbourhood Renewal are: • To ensure that the people living in the most deprived neighbourhoods have access to the best possible services and to the opportunities which make for a better quality of life and prospects for themselves and their families; and

• To improve the environment and image of our most deprived neighbourhoods so that they become attractive places in which to live and invest

Strategic Regeneration Frameworks – Each of the five Belfast Area Partnerships is currently developing a Strategic Regeneration Framework to guide development, investment and service delivery for the next 10 years. All stakeholders are working together to establish a clear and shared vision and implementation plan.

Lifetime Opportunities – This is the Government’s anti-poverty strategy. Amongst other things, it seeks to eliminate poverty and social exclusion, and tackle area-based deprivation.

Investing for Health – this is a cross-departmental government strategy which seeks to address the causes rather than just the symptoms of poor health. It recognises that health and well-being is largely determined by the social, economic, physical and cultural environment.

Community Planning and wellbeing – this is a new strategy which will be led by Belfast City Council. The Council will come together with other organisations and with local people to plan, provide for and promote the well being of communities they serve.’

Greater Shankill and West Belfast Task Forces – these are delivering programmes which enhance the employability of people in West Belfast and Greater Shankill.

Health Action Zone – this is a partnership of statutory, community, voluntary and private sector organisations working together to tackle inequalities in health and social exclusion. It works in disadvantaged areas of Belfast, and adopts a broad social model of health, recognising that the main factors which affect health lie outside the remit of the formal ‘health service’.

Belfast Healthy Cities – this aims to improve the health and wellbeing of people living and working in Belfast through an intersectoral approach. It aims is to work with decision makers to develop innovative approaches to create a healthy city. One of its key themes is healthy urban planning.

Belfast Community Safety Partnership – this is a partnership, led by Belfast City Council, which aims to make Belfast safer and feel safer. It is: • Targeting anti-social behaviour • Reducing alcohol fuelled hate crime • Dealing with hate crime

There are also a large number of local, community-driven initiatives, eg:

Healthy Living Centres – community led health and wellbeing initiatives delivering on eg drugs and alcohol, complementary therapies, stress reduction, weight management etc

Sure Start – working with children under 4 years and their families

Women’s Centres – running a number of programmes for women eg life skills, literacy and numeracy, parenting support, confidence building etc

Youth work – groups working with young people on a range of programmes, both centre based and street based.

After schools programmes – work with children outside normal school hours.

Restorative Justice programmes – working with offenders and their victims.

Drug and alcohol programmes – run by various organisations.

Sexual health programmes – generally targeted a young people to help them make informed choices about sexual health and relationships

Employment initiatives – helping people who are long-term unemployed to find work.

Healthy Urban Planning (HUP) Working Group – Green map of Belfast – Equity and Health training programme Belfast City Council – Corporate priority – Air Quality Action plans – Waste Management/recycling projects – Quality and development Control Guidelines for Developers Regional Partners – Department Of the Environment. Department of Social Development, Environmental Protection Agency.

There is a concentration of multiple deprivation in North and West Belfast, in marked contrast to the more affluent South and East Belfast. Noble’s Index of Multiple Deprivation in 2005 shows North and West Belfast to have 17 of the 20 most deprived super output areas in Northern Ireland.

The main problems, needs and challenges are: • High levels of unemployment (and consequent benefits dependency) • Low levels of academic achievement • High levels of relative poverty • Lack of good community relations • High levels of ill-health (including mental ill-health) • High levels of suicide and self-harm • High levels of teenage parenthood • High levels of drug and alcohol misuse • High levels of poverty • Fear for personal and community safety • Lack of open spaces and play areas

It is clear that there is a very strong relationship between poor health and social deprivation. A number of pieces of research in Northern Ireland over recent years have shown that a high proportion of the difference in health status across geographical areas can be explained by material deprivation. In areas, therefore, with high levels of poverty, health status is poor and a wide range of social and health related problems are more prevalent. People become ill or disabled at a younger age in deprived areas and their life expectancy can be reduced by as much as four years. And added to the poor health status, high levels of unemployment, dependency on benefits, educational under-attainment etc, North and West Belfast suffered disproportionately during the 30 years of the Troubles, with 40% of all fatalities occurring in this area. It is also very segregated on religious lines, with people living in communities almost wholly Protestant or Catholic. All of the initiatives listed above are active in North and West Belfast.

Theme 4: Use of Structural Funds in designing actions to develop "health gains"

Northern Ireland benefits from two mainstream Structural Funding programmes under the Competitiveness and Employment objective for the period 2007-13. The key objective is to help close the productivity gap between NI and other UK regions and to expand the private sector. ESF funding in Northern Ireland is channelled through and managed via a Devolved Government Department entitled “Department for Employment and Learning”. Its budget for the period 2007 -2013 is €165million. The overall aim of this programme is to reduce economic inactivity and increase workforce skills. Whilst these are inherently economic in focus, there is an indirect effect on health: the programme priorities of (A) Helping people into sustained employment and (B) Improving workforce skills, will assist those who suffer from health barriers back into the workplace. Therefore key programme performance indicators mirror health needs in this regard e.g. enabling training participants who have disabilities and/or health conditions to obtain qualifications. The Operational Programme for this funding was submitted to the European Commission in July 2007 and has had one call for funding – a second is anticipated in 2010. ERDF funding in Northern Ireland takes the form of the “European Sustainable Competitiveness Programme. It similarly was presented to the Commission in the summer of 2007 and finalised in November of that year. This programme aligns itself with the Lisbon Agenda goals of creating and sustaining a successful economy. ERDF funding to the region for the next seven years totals €307million and is being coordinated by a department within the Northern Ireland Assembly entitled the “Department of Finance and Personnel”. The Managing and Certifying authority functions however are the responsibility of another department, the Department for Enterprise, Trade and Investment (DETI). The ERDF Programme has 3 priorities: o Sustainable Competitiveness & Innovation (research and development); o Sustainable Enterprise & Entrepreneurship; o Improving accessibility and Protecting & Enhancing the Environment

Neither of the Programme’s expected outputs can be viewed as directly improving the health status of individuals – although the health sector may benefit from an increase in research and development expenditure should it successfully apply. The overall quality of life of inhabitants may also be indirectly improved through, for example, enhanced public infrastructure or access to services.

There are two ‘horizontal’ cross-cutting themes in the ERDF Programme A) Equality B) Creating Sustainable Development and Creating Sustainable Communities.

The Programme recognises that creating better living and working conditions and providing an attractive place to live and work will lead to an improvement in the quality of life for all. Belfast City Council has been a direct project partner in a number of projects which can be viewed as improving the health and quality of life of its citizens: (A) Brownfield European Regeneration Initiative – investigating approaches across the EU on how development opportunities can be maximised in regeneration zones. Funded via Interreg IIIC and further application submitted under new Programme (B) Connect Project – funded and completed initiative through the EU Programme for Peace & Reconciliation looking at how urban governance in the cities of Valencia, Rybnik, Stockholm and Vilnius can be improved to create modern, vibrant and equal cities

(C) Women into Non-traditional Sectors (WINS): transnational project led by Belfast and funded via Equal initiative examining how gender imbalances can be addressed in the labour market. Project had a particular focus on enabling women return to workforce. (D) SportUrban: partner in this Interreg initiative which sought to address how sport could be utilised as a tool for social, economic and cultural integration (E) Urbact Youth: formulating recommendations to enable young people to play a more active role in the decision making processes across Europe – thereby creating active citizens (F) Urbact Regenera: improving urban space and addressing modern urban issues across the EU (G) Urban Matrix: access to good practice in urban governance (H) European Year of Intercultural Dialogue: a transnational partnership of 23 cities funded through the Council of Europe looking at how cities can foster intercultural dialogue and improve social cohesion (I) Peace III Measure 1.1: focuses on “Building Positive Relations at the Local Level” and the Council has submitted a multi-million pound action plan that will enable local communities to identify local solutions to local problems in both of these fields (J) Interreg IVA Programme: again the Council is leading a bid for multi million pound support to improve quality of life via collaborative, tourism and economic projects that will directly affect local populations (K) European Year of Education Through Sport: BCC led the only Northern Ireland project funded by DG Culture & Education to establish models to improve play, physical education and sporting opportunities among young children (L) Peace II Measure 2.2: BCC is leading a project to develop Northern Ireland’s first purpose built outdoor urban sports park in the city – in an area of severe social and economic disadvantage. (M) Urb-Health – A thematic network cofounded by Urbact 1.

Please note – the above projects are only those in which Belfast City Council is a partner. There will be other projects funded through Structural Funds relating to health and improving quality of life which we will be unaware of or play no role.

At a regional level, there is a level of ignorance as to the potential SF opportunities to pursue these goals. The President of the European Commission established a specific Task force within Northern Ireland to improve the capacity and uptake of other EU Programmes within the region. Belfast City Council is viewed by Central Government as a “lead agency” and front runner in terms of accessing other EU sources of funding and this is due to the fact that it is the only local authority on the island of Ireland to have a team dedicated to this field. The result of this is that other agencies, statutory providers and key public service deliverers are unaware of, and do not have the capacity to pursue these opportunities. This baseline report sets a target of 50 new transnational partnerships to be built by the NI Assembly within this Programme period. Belfast City Council is now being approached by Government Departments to assist in this exercise. In addition the region is a highly bureaucratic and service delivery in these matters is very fragmented. As a result, if BCC wishes to establish a holistic project to address either subject, it is necessary to formulate a very extensive domestic partnership (in addition to securing European partners). The end result is that the project aims and objectives must meet the strategic objectives of a plethora of agencies in order to ensure buy-in. This can be a very time consuming and protracted experience. At present BCC does not have the remit for health nor level of competencies similar to those of other local authorities in Europe – this therefore reduces the opportunities for it to engage in transnational project proposals led by another EU public authority. For example if a projected output is to change policy in the domain of health, then BCC can not guarantee effective change.

Therefore in respect of need, Belfast can avail only of those opportunities which are flexible to local conditions and offer real tangible benefits to its match funding accountable department.

Sources www.belfasthealthycities.com www.belfastcity.gov.uk http://www.ninis.nisra.gov.uk/mapxtreme_ifh/report.asp? INIT=YES&POSTCODE=BT060HH&DESC=FromGeneral &CurrentLevel=COA&ID=95GG380003&Name=95GG380003&Tab=DC http://www.wellnet-ni.com/contact.php

EHSSB Investing for health Indicators

Lecce - Italy

Luigi Maniglio City of Lecce – City Planning Department 25 th of July 2008

General socio-economic context: current situation and main issues related to health

Lecce is a historic city in southern Italy as well as the capital of the overall province. Over 2,000 years old, it is the main city of Salento, a sub-peninsula at the heel of the Italian Peninsula. Lecce reached its highest splendour during the Roman age and during the XVII century. Today it looks like a play set where grotesque masks, volutes, cariatydes, angels , crosiers, flowers and fruits adorn the city centre which fascinates crowds of tourists during the day and spirits during the night with its “movida”. Messapian, pre-Christian, Roman ruins and Renaissance palaces are emphasized through cultural events throughout the year. Currently, the overall population is of about 93,529 people and the city needs to support healthy ageing as over 25,000 people are older than 60. (See figures)

POPULATION 93.529 (december 2006) 0 – 19 20 – 39 40 - 59 60 -79 80 + years old years old years old years old MALE 8.199 12.682 12.484 11.329 1.671 FEMALE 8.015 13.155 14.019 8.679 3.296 TOTAL 16.214 26.701 26.503 20.008 4.967

DEMOGRAPHIC PROFILE: MIGRATION YEAR MALE FEMALE TOTAL POPULATION RATE 1996 1045 806 1851 1.86 2003 1373 1310 2682 2.97 2004 1648 1606 3254 3.55 2005 1878 1799 3677 3.97 2006 2050 1945 3995 4.27 2007 2203 2213 4416 4.69

Demographic profile: MIGRATION Geographic areas MALE FEMALE TOTAL % AFRICA 545 240 785 19.6 REST OF 544 677 1221 30.6 EUROPE AMERICA 86 157 243 6.1 ASIA 766 591 1357 34.0 UE 107 277 384 9.6 OCEANIA 2 2 4 0.1 UNKNOWN - 1 1 0.0

LABOUR MARKET TOTAL MALE FEMALE UNEMPLOYED 8.0 6.4 10.5 PEOPLE IN ITALY UNEMPLOYED 14.7 11.4 20.0 PEOPLE IN LECCE EMPLOYED PEOPLE 62.5 74.5 50.6

IN ITALY EMPLOYED PEOPLE 55.0 67.2 40.6 IN LECCE

The Province of Lecce, also known as lower Salento was divided into three provinces when, in 1923 and 1927, the cities of Taranto and Brindisi were respectively added to Lecce. The sea is by the three sides of the peninsula and the coastline has more of Km 200 of total length. It starts from the Province of Brindisi (north), goes on by Casalabate down by the Adriatic side until Santa Maria di Leuca (south), then going back up by the Ionic side up to the boundaries with the Province of Taranto.

Lecce is the historic and economic centre of Salento, both because of its commercial and administrative importance and its geographic positioning in the middle of the Mediterranean green plain. Furthermore, its incredible monuments and architectural peculiarities, mainly in baroque style, make it unique in its genre by conveying an untouched old-fashioned atmosphere. Being a town of churches, monasteries and seminaries, Lecce manages an incredibly valuable historic and artistic legacy, a heritage from the past brought back to life through major architectural works. The economy of Lecce is based on TOURISM, AGRICULTURE and TERTIARY, however In the last years its territorial vocation is changing thanks to the new arising of industrial activities.

Urban Services Lecce, being the provincial capital city and headquarter of administrative institutions, offers a wide range of services: Cultural, artistic, sport and leisure facilities (museums, galleries, archeological areas, cinemas, theatres, book stores, libraries, editing companies, scientific research centres, municipal social centres, conference halls, associations, night clubs, sport facilities, etc.); Education facilities (primary and secondary schools and the University) Healthcare services; Security facilities, judicial and military corps; Hospitality services and refreshments; Commercial areas

Lecce and its reserves. The naturalistic park Lecce’s territory hosts an exceptional naturalistic heritage of flora where woods and the local Mediterranean vegetation, the so called macchia mediterranea , are widely spread all over the region.

Rauccio, a wetland which has been object of studies, project and protection initiatives, has been recognised as a site of importance for the community (SIC).

Health duties are divided according to the regional law n. 19/06 (art. 16-21). Duties of the Municipalities : To be responsible of all administrative functions regarding social matters at local level. They adopt the administrative setting which turns to be the most functional for the service management, effective with citizens as well as economically sustainable. The Municipalities, in accordance with the available resources set forth by the Regional Plan, must exercise the following activities: • Planning, structuring and realization of the local social services network, prioritization of the innovation sectors throughout the concentration of local human and financial resources; • Planning and management of matters involving school support and education; • Authorization, vigilance and control of social aid services as well as residential and semi- residential facilities; • Taking part to the territorial sections definitions; • Definition of the parameters for prioritization in the access to services;

Duties of the Province : help in the planning of the integrated social services system; • Data collection of needs and resources made available by the municipalities and other institutions in order to execute the regional information system; • Demand and supply analysis of aids in order to focus on relevant social matters by giving the necessary support to coordinate territorial interventions; • Promotion and realization of training initiatives; • Structuring and management of interventions involving school aid and education; • Defining and executing area plans (Piani di Zona); The Provinces play a coordinating function in the planning and provision of social aid, they support the municipalities in the joint management of social services and contribute to training.

Duties of the Regional Authority : plans and coordinates the construction of an integrated system which aims at social wellness and good quality of life. The regional authority defines the territorial areas of intervention and the tools for the management of the local social services system; • Approves the regional plan of health polices and assigns the financial resources; • Finances and promotes the development of services, the protection of social rights and the experimentation of innovative interventions; • Promotes, finances and coordinates the technical assistance for the set up and management of social interventions by local institutions; • Defines the requisites and procedures for the authorization for the facilities and social aid or health services both public and private; • Determines the standards of vigilance of public and private facilities and services of social aid; • Defines the criteria for the concessions of licences for social services; etc.

Theme 1: Health Impact Assessment (HIA) and the use of urban health indicators

Lecce is interested in working on Health Impact Assessment as it has no direct experience in using HIA for developing its city regeneration strategies. It would like to create a useful toolkit for urban planning and regeneration policies related to citizens' health. As far as Lecce is concerned, urban health indicators relate to projects of urban policy – sustainable development indicators, with reference to the project POR PUGLIA 2000-2006

AXIS V “Cities, local administration and quality of life” MEASURE 5.1. “RECOVER AND REQUALIFICATION OF URBAN SYSTEM” . Measure 5.1 fosters the recovery and improvement of the urban quality of the town as well as the development of managerial functions and of competitiveness of regional urban systems.

The objectives of the project: • To enhance the usage of the urban space by citizens; • To reinforce the potentiality of urban centres as poles of attraction; • To reinforce the social presence by satisfying basic social needs; • To lead an urban requalification process in accordance with cultural and historical traditions of specific areas;

Projects have been selected according to the following criteria: • Initiatives aimed at the improving the quality of supply through the requalification actions; • Creation of new facilities in areas where the current supply is deficient; • Initiatives aimed at enhancing the environmental efficiency; • Initiatives sponsored by consortia of firms aimed at valorisation and fostering value chain activities; • Compatibility with the municipal sector planning; • Widening of labour force recruiting also in favour of disadvantaged individuals; • Equal opportunity and treatment (based on VISPO criteria).

Indicators which strictly relate to matters involving health and quality of life are the following: 1. Social indicators (i.e. social centres realization): number of individuals which can take advantage of the centre ; 2. Road building/ requalification : indicator expressed in kilometres (Km); 3. Quality of life : number of inhabitants in the area of intervention;

Our expectations as regards the implementation of HIA is : - creation of a useful toolkits for urban planning and regeneration policies related to citizenship health.

Theme 2: Policies and actions for an active and healthy ageing

Various actions have been undertaken by the Municipality of Lecce for the benefit of elderly people. Meetings between representatives of elderly people (Pensioner Unions) and the municipality executives are periodically held. On the one hand, these meetings turn out to be a useful confrontational tool between executives and people, the Unions’ representatives, who are able to better monitor needs and requests of the category they represent. On the other hand, they reinforce the attention for elderly that the Municipality has had over the last few years also through numerous and significant initiatives. Amongst these initiatives there are: • A targeted reduction of taxation [i.e. Abolition of ICI for the first home, given the fact that most of the elderly owns their home, reduction for Tassa Smaltimento Rifiuti]; • The completion of the institutional web portal [i.e. completion of the portal for a more complete utilization by a different range of individuals]; • The creation of the service “vigili nonni” ; • the opening of social centres [i.e. Opening of new social centres in the town periphery]. Another important initiative involves the diffusion of the Municipal Services Brochure (Carta dei Servizi Comunali) as an information vehicle.

VIGILI NONNI – Surveillance service performed by the so-called “vigili nonni” outside of schools in order to grant kids a certain level of security at the beginning and end of classes. The initiative will continue to exist as long as there will be a wide support from families and school deans, as it has been over the last few years. In addition, the elderly can also refer to the elderly office (social services). This office aims at safeguarding the elderly people’s dignity and autonomy in order to prevent any uneasiness and promote psycho-physical wealth through various personal services as well as support, integration and socialization activities.

To whom it is addressed: To all the resident elderly people. Access to the services can be direct or indirect.

Main activities:

Home assistance for social needs, which includes: 1. Home services: 1.1. Personal care assistance 1.2. Assistance and support for house keeping matters (i.e. cleaning, basic shopping, support for medical prescriptions) 1.3. Assistance for transfer to local facilities 2. Nursing service 3. Meals delivery (outsourced) 4. Laundry service with home pick-up and delivery (outsourced) 5. Emergency service through the installation of an emergency device (Beghelli) onto the phone landline Introduction into specialized and legally recognized facilities.

This service represents a means of assistance when specific socio-sanitary and family problems exist, which prevent the usual permanence of the elderly at her home. In cases of proven economic disadvantage of the elderly in question and of its close family, the municipality would contribute to the payment of the rate; the initial payment requested would be proportional to the retirement compensation the applicant has.

At the moment a Strategic Plan for the city is being defined by the Municipality as par of a wider plan for the area ( Area Vasta ) which Lecce is a leader of. A great challenge for our city is to plan in a unitary way the coordination of provision of services of social health not only in the urban area but also in the so called Area Vasta . Furthermore, in line with the previous work done by the Province of Lecce and by the local health provider (Az. Sanitaria Locale), there has also been the so called Project “Welfare”. This project led by the strategic plan office has involved a multitude of players being them institutional, social, economic or politic ones, through the execution of strategies of institutional cooperation. In this context, has also been created a workgroup focused on the development of the project sponsored by the Institute for Microelectronics and Microsystems (IMM) – CNR which involves the so called “ambient assisted living”, a set of innovative technologies aimed at improving safety, health and the overall quality of home life for elderly and people with disabilities.

Theme 3: Healthy Places and Healthy Environment

Here below we list the main problems in connection with the quality of life in our town: • Almost absence of green areas; • Overall town cleaning, which has not sufficiently reached the standards of separate collection of items for recycling yet; • Problems linked with the labour market; • The problem of parking and the scarce use of public transportations (Lecce has many roads but few parking areas). As far as public transportation is concerned, the next opening of the new “on-the-ground tube” ( metropolitana di superficie ) will complete the whole offering package of public transportation in town with the goal of neutralizing problems connected with mobility; • The security of neighbourhoods; • Absence of places for socializations (addressed to young people); • Few sport facilities; • The problem of stray dogs; • In the summer season it is recorded an increase in problems connected to forest fires, street accidents and coast guarding due to the massive presence of tourists. A great deal of work is done by the civil defence.

In order to safeguard the public safety and health there are some laws which impose limits both in the streets (driving codes) and in relation with building. a. As far as the absence of green areas is concerned, over the last few years Lecce has planted new trees and Mediterranean vegetation in the newly developed squares (Orange and linden trees, etc.), the recovery of the central park, the so called “Villa comunale” the only green area in town. There are a few projects in pipeline, such as the realization of a biking and jogging lane in Piazza Palio (periphery) and the green planting in a wide area connecting two separate sides of the stadium neighbourhood (periphery); b. Tailored public campaigns have been organized in order to boost the separate items collection for recycling waste; c. There has been created a new immigration desk and many initiatives are taking place aimed at bettering the quality of life of foreign people who choose to stabilize in our town (i.e. the realization of dorms, the multicultural library and financial support sponsoring); d. Creation of a “park for dogs” based on a model used by other Italian towns; e. As far as labour issues: there is a rediscover of the ancient jobs (mission of Urban a “Community Iniative”). Thanks to “ Urban” , started from an EC initiative in 1998 - 2001, together with the revaluation of the building and infrastructural structure of the historic city- centre, there have been many initiatives focused on entrepreneurial training, job opportunities and the social dimension in general aimed at integrating foreign people and creating support facilities to the weak parties in the city, thus widening the welcoming channels. The historic centre has been the object of various works which are helping to rediscover the old paving, which has laid for years under the numerous layers of concrete and dust, as well as revaluating the façades of old buildings which will emphasize the architectural beauty of the town; f. Parking areas: There are development plans aimed at easing the traffic and developing common areas for public transportation; g. Security: Institutionalization of the neighbourhood security which collaborates with the regular police; h. Regeneration of peripheries: the already existing sport facilities of local churches are being developed even more in order to create more socialization spots.

Up to few years ago, the historic city-centre used to be considered a “bad neighbourhood”. Thanks to P.I.C. Urban this area has undergone a deep evolution and planned revaluation which has made of it a well-liveable place. As of today, some peripheries could be considered “unhealthy” part of our town. Indeed there are numerous problems there: the absence of green areas, street cleaning, neighbourhood safety, absence of socialization spots, environmental protection and elimination of polluting factors. In addition, one of the problems that few decades ago was not considered (while the editing of the General Urban Plan was done)is the localization of electric pillars. Indeed, based on the original city building structure, these electric pillars were originally located on the external boundaries of the town centre (the actual periphery) and therefore did not create any issue concerning the traffic flow and citizens’ health. Now, also thanks to the development of residential and non-residential areas, the situation appears to be completely different and the new expanded neighbourhoods now happen to incorporate the areas where these pillars were located. The local municipal administration find itself in a position in which has the moral obligation to tackle these issues in order to safeguard citizens’ health. This can be done through the elimination of such old-fashioned technological elements which continue to create dangerous electromagnetic fields. This objective can be met by laying the high voltage cables in the underground through a project which should involve the collaboration of the energy companies in charge as well as of the local public entities. Lecce will involve the Managing Authority, the health local administration “ASL Le/1” and the Regional Agency for Environmental Protection (ARPA) in the Building Healthy Communities network.

Theme 4: Use of Structural Funds in designing actions to develop "health gains"

The so called POR (i.e. Regional Operative Program) is the document useful for the planning of the usage of Structural European Funds complemented by the ones granted by the Ministry of the Economy and Finances as well as the ones granted by the regional authority (i.e. Regione Puglia). Thanks to the opportunities offered by the European financings, Puglia has started and completed numerous initiatives which foster the development of the local economy and would allow at the same time to play a leading role in the international economic arena.

A document concerning the planning of the new POR 2007-2013 is currently being discussed. Nevertheless there will surely be specific provisions concerning the quality of life in the whole Region and specifically within cities, in order to foster a continuous territorial and local development. The Managing Authority of the 2007-2013 OP for our region is Mr. Luca Celi.

The main pillars of the program “POR Puglia 2007-2013” are: 1. The valorisation and fostering of research and innovation to enhance competitiveness; 2. The efficient and sustainable use of natural resources and energy to foster development; 3. The social commitment and development of services aimed at improving the quality of life as well as territorial appeal; 4. The valorisation of natural and cultural resources for local development; 5. The creation of networks and facilities to ease mobility; 6. The push to competitiveness of labour employment and of productive systems; 7. The improvement of competitiveness and appeal of cities and urban systems;

8. The creation of effective governance and institutional structures as well as competitive and functioning markets;

The third pillar pursues the objective of creating better life conditions, cohesion and social inclusion and commitment. (Taken from Regional D.R. 12/02/2008 n. 146 P.O. FESR 2007/2013. Approval following to the decision CE n. C/2007/5726 of the 20/11/2007.)

POR PUGLIA 2000-2006 AXIS V “Cities, local administration and quality of life “ MEASURE 5.1. “RECOVER AND REQUALIFICATION OF URBAN SYSTEM”.

PROJECT GOALS: The measure 5.1 is aimed at reinforcing the urban system of the region, valorising factors of competition, through a greater integration of interventions, a strong institutional, economic, social partnership, the involvement of the private sector in project funding, and the promotion of consolidated experiences of governance and planning. The project aims at improving the functions and the quality of urban systems through the improvement of economic, administrative and social conditions, so that enterprises and new initiatives can develop in the urban areas, with particular attention to environmental issues. In particular the project defined 5 lines of intervention: a. Multi-functional and environmentally-friendly re-urbanization of urban space; b. Management and employment pacts; c. Integration of subjects on social exclusion; d. Integrated public transport and communication; e. Improvement of local governance. The measures of POR 2000-2006 connected to the measure 5.1 are: • Measure 4.17 Action C “INSTALLATION OF NEW COMMERCIAL ACTIVITIES, RESTRUCTURATION AND MODERNIZATION OF THOSE ALREADY EXISTING PROMOTED BY MICRO ENTERPRISES (LESS THAN 10 EMPLOYEES) IN THE URBAN CONTEXT”. • Measure 5.3 ACTION B “ SUPPORT TO MEDIUM ENTERPRISES IN THE URBAN CONTEXT” The programme establishes, moreover, a pilot project on urban development denominated TISSUE “Twinning for Integrated Support to Sustainable Urban Europe” aimed at experimenting methodologies of regional development through the use of strategic planning as model of regional governance, included in the context of the line E “Improvement of management and of governance process” Measure 5.1.

ROLE OF THE MUNICIPALITY OF LECCE: Body beneficiary of the financing and of the realization of programme.

The Municipality of Lecce is active, in particular, in best practice exchanges with European, national, regional and local institutions. For instance it has signed many partnership agreements with European cities and it has participated in networks and collaborations with associations and local, regional national, European administrations - also considering the challenge of the structural funds 2007-2013, which have a considerable impact on urban planning and urban development. The goal is to reinforce the citizen’s dimension at the European and national level and to develop an administrative action to fulfill the strategic objectives put down in the EU economic and social cohesion policy (in accordance with the goals defined in Lisbon and Goteborg). In this way, the Municipality of Lecce, playing as partner within a network, can aim at realizing sustainable growth in a more competitive territory.

In addition, an important project sponsored by the Communitarian Policy Dept. is the so called URBAN (ref. PIC URBAN – FESR – FSE 1997-1999) thanks to which the following objectives have been achieved: • The support to economic activity with particular focus on valorisation of local productive talents (see MESURE 1 – start up of new economic activities – support to craftsmanship and local PMI – creation of commercial centres/show rooms); • The boost and development of employment in order to tackle the problem of ostracism and long term unemployment (MEASURE 2 – increment of local FSE employment and training – training programs for disadvantaged people, school of craftsmanship, support and financing to firms in the cultural (cultural heritage management) sector); • The social integration of immigrants as well as the promotion and diffusion of the equal opportunities’ culture (MEASURE 3 – social services, health, public order – interactive desk for women and information and assistance desk for immigrants); • The improvement of the environment and infrastructures throughout the recovery and reuse of places which turn to have an important historical and artistic meaning (MEASURE4 – infrastructures and environment – recovery and functional refurbishment of historical real estate assets intended to specific destination of use, in accordance with the URBAN project – interventions of environmental requalification of public spaces);

The interventions foreseen in the plan are mainly concentrated in the so called area Giravolte (in the historic centre ). The following works have been performed: • Renewal and realization of the original hard chalky brick planking; • Resetting of specific parts of existing systems (i.e. electrical or telephone network system, etc.) throughout the path reorganization and burying of cables; • Improvement of the lighting system throughout the installation of lamps, in line with the aesthetic historic context, in order to grant better safety conditions to the area; • Installation of various elements (i.e. bike racks, news kiosks, green spots, etc.) which useful for the requalification of the area; • Historical and artistic signage for the main monuments and architectural heritage; • Extraordinary maintenance to infrastructure in order to ensure fairly high living standards to residents

Difficulties in obtaining information and reach the responsible parties in this particular period (summer holidays and closing of some offices); Existing information are fragmented and not organically gathered. Furthermore, not having specific competences for the issues treated the task turned out to be even more challenging.

Sources http://por.regione.puglia.it/index_it.php?id=0|0 http://www.comune.lecce.it www.regione.puglia.it

Lidingö - Sweden

Jeccika Eriksson and Johanna Berg City of Lidingö - City Executive Office and Consulting and Advisory Services Department 17 th of July 2008

General socio-economic context: current situation and main issues related to health

Education and labour market The municipality of Lidingö is an island situated in the Stockholm county with a short travelling time of only 20 minutes with public transport to the centre of Stockholm. The island has a green environment with lots of recreational areas and proximity to water. This makes Lidingö a popular place to live when working in the Stockholm region.

The about 11 500 job opportunities within Lidingö are mostly to be found in health- and social care, retail and communications, education and in finance. There are no larger industrial areas on the island, but there are a large number of companies. Most of them are very small (micro size), many of them consulting bureaus within business, management and PR. In total, there are about 5 000 employees travelling to Lidingö every day, and 13 300 travelling for work outside the municipality.

The population of Lidingö has one of the highest levels of education in Sweden. 59% of the inhabitants have post secondary education or higher, meaning Lidingö has the third highest education level in the country. Corresponding proportion for Sweden in total is 36%. With a well-educated population, Lidingö has a very high rate of doctors, persons with legal education, persons with business administration education and masters of engineering. The mean income is consequently high, placing Lidingö as third in Sweden in total.

Unemployment levels are very low, compared both to other parts of Sweden and with the Stockholm region. In 2007, the unemployment rate was 1.2%, in Lidingö, to be compared with 2.9% in Sweden. The working population constitutes 78.5% of the population.

Demography and population Lidingö has in total 42 710 inhabitants, and has an increasing population thanks to rise of births and a positive net migration. In the past few years, Lidingö has experienced a baby boom, resulting in a large number of younger children. However, birth rates are expected to decrease in the coming years.

Age structure 0-18 years 19-64 years 65+ 80+ Sweden 22.4% 60.1% 17.5% 5.35% Stockholm region 23.2% 62.6% 14.2% 4.35% Lidingö 25.1% 56.6% 18.3% 6.63%

Gender structure Lidingö Women 52.2% Men 47.8%

Lidingö has today a high proportion of elderly inhabitants (65 years of age or older), and in a near future an additional large amount of Lidingö citizens will turn 65 years of age, which also

means that they will exit the workforce. Citizens of Lidingö have the highest life expectancy in Sweden: 80,58 years for men and 84,37 years for women.

16.7% of the population has foreign background (foreign-born persons and persons born in Sweden with both parents born abroad). The most common countries of origin, outside Scandinavia and Western Europe, are Poland, Chile, Estonia, USA and Iraq. Many immigrants live in Högsätra, Käppala and Larsberg, areas with mainly apartment blocks.

Dwellings There are more apartments than villas in Lidingö, but since there are usually more residents in a villa (very often families with children), about half of the population lives in apartments and half in villas.

Rented apartments 8 500 Owned apartments* 4 400 *a complex of dwelling units in which each unit is individually owned Villas 7 100 Total 20 000

There are a high proportion of single households in the municipality, 23.8% compared to 22.2% in Stockholm region.

Health status In 2007 a vast survey was performed in the Stockholm region, asking inhabitants in all municipalities a large number of questions about their health in all aspects – physical, mental and social. For Lidingö, it was shown that 78.6% found their general health good or very good, as compared to 72.2% in the region in total. It also showed that 1 in 3 is affected by a long-term disease, health reduction or handicap, which is a low number in comparison.

The same survey also showed that almost half (49.1%) of the working population has a sedentary work, showing this is more common for Lidingö citizens than in the Stockholm region in total (41.1%). This indicates additional physical activity may be extra important for Lidingö citizens. 8.2% says that they are not physically active at all in their free time.

Health issues There are big gaps within Lidingö concerning educational and income levels, and so also concerning health. Lidingö is not a homogeneous city, even thought the mean income might be high, 5.7% of the children in Lidingö are living in families with low income standard. 12% of the population has in the last 12 months refrained from visiting a dentist due to economic reasons. 3% has refrained from seeking medical help and 3.3 % has not bought needed medicine of the same reason.

The health survey gave worrying information about the mental health situation. One forth of all women aged 18-44 states they suffer from mental ill-healthiness (e.g. worry and anxiety), and 11% of the population has been diagnosed with nervous exhaustion. Among the men, about 17% has drinking habits that count as high-risk consuming (drinking alcohol in an amount equal two bottles of wine once a week or more often). Almost 25% of the citizens experiences stress several days a week.

Elderly One forth of the elderly (over 65 years of age) answers in the survey that they rarely meet relatives, and 3.6% of all elderly says they are plagued by loneliness daily or several times a

week. By the other hand, it is common for the elderly population to engage in collective activities – almost 70% had taken part in such an activity the last year.

Among the elderly, 15% is lacking essential service (banks, grocery stores etc) in their neighbourhood, and almost one third states they are afraid of being outdoors in evenings and nights. 12% has problems getting around outdoors and is depending on auxiliary means such as walkers, and there are so many as 24% who are not physically able to walk 100 meters. Furthermore, many elderly have trouble hearing, and 3% is not able to read a text in a regular newspaper, it is clear that the risk of isolation is big.

Theme 1: Health Impact Assessment (HIA) and the use of urban health indicators

The Stockholm region is now working with a new regional development plan. In this work, health issues have been involved and the relation between public health and development planning has been examined. This perspective on development planning is fairly new. In Sweden, the most common methods are Health Impact Assessments and the use of Health Indicators. Many actors in the Stockholm region have started working systematically with public health. Also The National Institute of Public Health has presented a method to work with public health in programs, policies and plans, such as the regional development plan, and recommends the use of HIA. Within the Stockholm County Council, a first HIA was performed during spring 2008 in order to get more experience of the method. During this project, public health experts worked together with urban planners with analysing the health consequences of the new regional development plan. The project resulted in suggestions on how to improve the practical work with HIA, and many of the project participants appreciated the new way to work with health integrated with other issues. Hopefully, it will be possible to perform further HIA:s later on in the process of the regional development plan. The City of Lidingö has yet no experience of performing HIA:s, but hopes to learn from the experiences and use inspiration from the work that has been done within the region and among the partners in this network.

Health indicators in national public health The indicators used in the Stockholm region are based upon objective domains for the national public health policy. These objective domains are as follows, and to each of them there are examples of indicators connected. Please note that these indicators are examples, and may be changed depending on situation and when additional data is accessible.

1. Participation and influence in society Statistics on participation among voters in elections, statistics on equal opportunities 2. Economic and social security E.g. unemployment, income and education level, crime rate 3. Secure and favourable conditions during childhood and adolescence E.g. eligibility for university education, public resources for children 4. Healthier working life E.g. work related injuries, sick leaves, level of influence at work 5. Healthy and safe environments and products E.g. injuries, poisoning, suicides, pollution, how the community is adapted for the disabled 6. A more health-promoting health service E.g. number of health-promoting hospitals 7. Effective protection against communicable diseases

E.g. child vaccination, presence of sexually transmitted diseases 8. Safe sexuality and good reproductive health E.g. number of abortions 9. Increased physical activity No existing nationwide indicators on municipality level 10. Good eating habits and safe food E.g. breastfeeding frequency, mortality in cardiovascular diseases 11. Reduced use of tobacco and alcohol, a society free from illicit drugs and doping and a reduction in the harmful effects of excessive gambling E.g. liquor licenses, alcohol sale, smoking among becoming mothers, mortality related to alcohol and tobacco. No existing nationwide indicators on drug abuse and gambling on municipality level.

In Sweden, the accessibility to useful statistics on health is fairly good, even on municipality level, as can be seen on the indicators above. The objective domains and health indicators are including many aspects of health, placing health in a wide perspective. Factors as good education, sufficient income, absence of crime etc are seen as utterly important to a good health.

The Health Strategy of Lidingö When the City of Lidingö started its work with health, a community report on the citizens’ health status was put together (Samhällsanalys 2005 – Hur mår Lidingö?). The report presented facts and statistics on the citizens’ education, income level, living, crime and the islands physical environment as well as more medical indicators of health (e.g. weight, alcohol consumption, heart attacks etc). Moreover, the report included interviews with a large number of officials, who in their daily work met Lidingö citizens, children, youth and elderly, in their positions as nurses, youth club assistants, social welfare secretaries, home health aides etc. This mapping was the base for the Health Strategy that was adopted in 2005 and since then sets the focus for the city’s work with health, in all the city departments. The Health Strategy focusing on social, psychical and mental health and contains of eleven focus areas:

1. Sport activities should lead to healthy lifestyles 2. Alcohol abuse amongst young people and high-risk consuming among adults should minimize 3. Mental health amongst young people should be improved 4. Eating disorder, smoking and drug taking amongst young people should be minimized 5. Elderly people should be less lonely 6. The employees of the local authority should be healthier 7. The noise levels in Lidingö should diminish 8. The physical activities of school children should be stimulated and the parents should be encouraged to let their children walk to school 9. Overweight among adults should decrease and physical activities increase 10. The health of socio-economically weak groups should improve 11. The environment should be healthier Public Health in the Stockholm region Every forth year, Stockholm County Council performs a questionnaire study among the citizens of the region, asking a large number of questions about their health in all aspects – physical, mental and social. The latest study was performed in 2007 and gave valuable information about the health status in Lidingö. Also in this study, the understanding of health is based on the national public health objective domains. The study also explores the geographical diversity of health within the region, putting health in a socio-economic context.

Lidingö has worked with health, in the sense of wellbeing, since the city adopted the Health Strategy in 2005. A large number of projects have been realized, which has woken the need for better evaluation methods. Consequently, the use of urban health indicators is of great interest. This method would help Lidingö in terms of better understanding of health factors on Lidingö, better planning and evaluation of projects and more integrated projects. Using HIA and health indicators would also be a way to better implement and secure healthy thinking in the decision-making process. Today, we have the healthy thinking but need to find a HIA-method that suits the needs in the city. Exchanging knowledge among the partners will therefore be a valuable asset.

Theme 2: Policies and actions for an active and healthy ageing

Responsibility for health and medical care in the Swedish health system is divided between the state, county councils and local authorities. The local authorities responsibilities are to ensuring that their residents receive help and support needed and for care of elderly people and people with disabilities living at home i.e. - That elderly have the possibility to live independent in a safe environment and have an active life of good quality. - That elderly are provided with housing - That elderly have support and service in their home, and other services needed such as shopping or assistance when going for a walk.

In the Health Strategy for Lidingö is one of the themes directly liked to elderly; ‘ elderly people should be less lonely’. The state have during the past years funded actions to develop preventive health activities in the municipalities. Healthy ageing is not only an asset for individual well-being but also economic growth for the community and might also be an investment for workforce supply problems. A healthy elderly can live in their home longer, and have less need of home-care assistance and therefore lower the costs for the local authority. Elderly people in the Stockholm region are relatively healthy. But, an ageing population will lead to greater numbers of older people living with disabilities. Since the life expectancy is high in Lidingö this might mean many years with ill-health. Also, women live longer and request more medical consultations and treatment compared with men. Health reports shows that elderly have better functional ability, but more health problems compared to earlier. Among the elderly it is common with social isolation and mental ill-health. And even though we have knowledge about the importance of social wealth and individual well-being are we nationally and locally lacking a strategy with preventive measures.

Challenges The City of Lidingö needs to develop actions and work procedures to increase good conditions for elderly to live an independent and normal life, with the base in the individual needs, wishes and values. The City of Lidingö is in need of putting even more emphasis on preventive health activities. A lot of caring for elderly are taking place in the family and is performed by relatives, sometimes informal and sometimes paid by the local authority. The home carer is not always given the support and help needed and this can lead to increased risk of ill-health for the carer. From 2009 a new legislation will be introduced that extend the responsibilities for the local authority to support those who are caring for a relative. This legislation includes a health perspective for the carer. A healthy carer also means increased ability to care for relatives for a longer period.

Beyond social activities, we are also in need to continue to develop the access to physical activities that suite the elderly and their needs. And as stated in the section regarding healthy places is a safe outdoor environment as well as accessibility of high importance for the elderly.

Planned actions The Lidingö Elderly Care Department has decided that during 2008 and 2009 actively develop preventive health activities trough preventive home visits and finding new methods of co- operate with voluntary associations. The aim is to increase the accessibility to social contacts, better health and a more active life for the elderly.

Preventive home visits Since Lidingö has a high proportion of elderly inhabitants there is a huge need of prevention actions to give the citizens a good and active life for all, also for the elderly 80+. A healthy ageing population means that the elderly can live home longer, have less need for elderly care and also are in less need of health services and hospital treatment. A new project is in progress (autumn 2008) focusing on preventive home visits. The aim is to tackle the increased social isolation among the elderly population. This isolation leads to loneliness, poor eating habits that leads to ill-health and falls that may need hospital treatment. Through the home visit are the expected outcomes an increased competence how to work health preventive among the elderly.

Co-operation with NGO The co-operation between the city and NGOs is rare in Lidingö and these needs to increase. The city has a need to develop and find a social dimension for the elderly, but also to find methods how to engage individuals interested in voluntary work. Lidingö is aiming to develop an elderly care that involves the voluntary sector. We are therefore in need of finding new methods of cooperation. To be successful in this it is necessary to increase the knowledge among the staff about the advantages to co-operate with the voluntary sector. The city has neither clear goals for voluntary work, nor a common value-system today. The city is prioritising to do a policy regarding this that will be integrated in all work within the elderly care unit.

One of the challenges with the work of health promotion is that the focus always has been on ill-health and illness. The qualifications regarding health promotion is low among the staff and the issues are not discussed sufficiently and we need a change of thinking. See above.

Theme 3: Healthy Places and Healthy Environment

The Community Report made by the City of Lidingö in 2005 showed that several inhabitants have good chance to have a healthy life. There are some things though that needs to be improved. There is some damage on the island. Viaducts and walking- and cycle paths are covered with graffiti, which creates an unsafe feeling, since the areas feel deserted. An environment not maintained affects people in a bad way. Apart from the damage, people complain about the litter spread all over the island. To give access to activities for all it is important to improve the possibilities to spontaneous activity. Almost every second man over 18 and forth woman suffer from overweight or obesity (BMI>25) so it is important to be able to exercise on an everyday level. This also includes developing outdoor accessibilities for disabled people and elderly. Winters with very little snow leads to a darker outdoor environment, that affects being outdoors in a negative way.

The Health Strategy

100

The Health Strategy is divided into eleven focus areas, of which some are about the current topic healthy places and healthy environment.

● Sport activities should lead to healthy lifestyles; - Improve the conditions to be able to exercise spontaneously - Create more open meeting places ● The noise levels should diminish; - Fewer cars in school areas - Make a new noise evaluation ● The environment should be healthier; - Encourage local initiatives - Access for all

The Council of Preventing Crimes ( Lidingö brå ) Lidingö brå shall work to increase the safety and decrease the criminality in Lidingö. They shall improve and make the best use of the assets within the different sectors aiming at preventing crimes and preserving a social commitment. The current projects within Lidingö brå to obtain a healthier environment are as follows; 1. Project ‘To Prevent’ aims mainly to rebuilding facades to make graffiti painting inaccessible, e.g. by using trellis or vegetation. 2. Neighbourhood watch where neighbours and the Police work together to create a pleasant atmosphere and decrease housebreaking. 3. Policy against graffiti aims at breaking the upward graffiti trend by faster clearance of graffiti, a better coordination and a faster procedure to catch the perpetrator of graffiti. 4. Night walks means that adults are outdoors at weekend nights when a lot of youths are out. Their purpose is to make Lidingö a safer place during nights.

Other policies and actions Vision 2010 The Cultural Activities and Recreation Department does every third year a survey in the schools (compulsory-school and upper-secondary school) to find out about youths´ lifestyles to be able to offer them attractive leisure activities. The results showed that priority should be given to sports, youth clubs and other meeting points, culture, nature and in last hand other club activities. With a base in the survey a policy, Vision 2010, is developed that recognizes the importance of a healthy environment and healthy areas. The aim is to create more meeting places, to make leisure activities more accessible and to increase the civic participation.

Accessibility Policy An Accessibility Policy was passed by the Technical Service Committee in 2005. Aiming that easily removed obstacles will be attended to gradually. Disabled people, of whom many elderly will have all the requirements to be able to move outdoors, to exercise and to have access to different social areas.

Public Lighting A policy of Public Lighting is compiled to improve the light in squares, streets, roads, walking- and cycling paths and playgrounds etc. Lighting is an absolute necessity to be able to be outdoors during the dark months of winter. Lighting is also an issue of equality, many women avoid dark areas which makes their mobility limited.

Högsätra Högsätra is a residential area on the south east of Lidingö. The area covers most of the essential services within walking distance. There are schools, hospitals, retirement housing for the elderly etc. There are also an upper-secondary school and shops, which are frequented by the

101

inhabitants of the island. It is a busy area. In Högsätra there are private owned or rented apartments. The area is dominated by apartment blocks from the 70: ies. The inhabitants consist of a good mixture of young families with children, teenagers and retired people. Around 40% of the people living in Högsätra have a foreign background; either themselves and/or their parents are born abroad. The unemployment rate is comparatively high, especially among immigrants from outside Scandinavia. The educational level is also considerably lower in Högsätra than in Lidingö in general, both for men and women.

Main problems and needs There is a lot of damage and littering at Högsätra. The damage is mostly graffiti and glass- breaking. There is also damage on buildings and lamp poles. The littered area is close to the shopping area. The walking-and cycling paths are also very badly maintained. There are a lot of outdoor activities at Högsätra for the youths. The goal is therefore to minimize this concentration of young people in the streets of Högsätra and have a mix of generations. This is important since the more heterogeneous a group is the lower the risk of confrontation. Regarding the crime rate at Högsätra it is somewhat higher than in similar residential areas in Lidingö. One third of the crimes are theft, of which the majority hits the individuals. Then there is damage followed by threat and abuse. These crimes affect people’s everyday life. Many of the crimes are committed in public places which mean that every one living in the area is affected.

Challenges To be able to improve the environment at Högsätra it is very important that the inhabitants and visitors feel comfortable. Without their co-operation and willingness the efforts will be just efforts and there will be no permanent change. There must be co-ordination between the city and other interested parties to make the policy effective. If not the efforts will be worthless and no change will be achieved.

Planned actions Healthy area hikes To increase peoples participation and to inform them of the current problems so called safety walks have to be done at different hours and in different places. That means that you walk around in the residential area and keep your ears and eyes open looking for unhealthy areas. The participants should be representatives from the community, tenants, clubs and the police. After every walk one has to make notes to see what has to be improved. Lightening Improved lighting according to the policy of public lighting.

Possible actions Neighbourhood Watch Increase Neighbourhood Watch to also concern residents living in apartments. Today Neighbourhood Watch mainly applies to detached households.

Taken actions The group of Högsätra In the autumn of 2007 athletic clubs and representatives of the city gathered to cooperate concerning damage and disturbance. The group meets twice a year and has improved cleaning, sanitation and lighting in the area of the sports arenas. Camera surveillance of a sport area In the area there’s a sports arena that is heavily hit by graffiti. The arena is close to a comprehensive school so it’s important to keep the building clean from graffiti to avoid new recruiting. The cost of sanitation is also very high.

102

Theme 4: Use of Structural Funds in designing actions to develop "health gains"

Sweden have the European Regional Development Fund (ERDF) and the European Social Fund (ESF) and have identified four national strategic priorities for regional competitiveness, entrepreneurship and employment: • Innovation and renewal • Skills supply and improved workforce supply • Accessibility • Strategic cross-border cooperation In Sweden, one national and eight regional programmes are working under the "Regional competitiveness and employment" objective. The eight regional programmes are called Regional Structural Fund programmes for regional competitiveness and employment. They work on the ‘Innovation and renewal’ and ‘Accessibility’ priorities. Measures are adapted to suit the specific regional and local conditions. The regional programmes are funded by the European Regional Development Fund and Nutek is the managing authority. The National Structural Fund programme for regional competitiveness and employment works on the "Skills supply and improved workforce supply" priority. It is funded by the European Social Fund and the managing authority is the Swedish ESF Council. European Social Fund Sweden (approval date 2007-09-28) There are two priorities in the Swedish ESF Operational Programme that address the major employment challenges that have been identified. Gender equality is a priority across the whole Operational Programme, including funding projects to improve skills to eliminate gender-based segregation on the labor market where such gaps are identified.

Priority 1: Skills supply Activities will focus on employees and entrepreneurs in the public and private sectors and the social economy. Support will be offered to develop relevant skills, comprising a careful analysis of needs followed by appropriate training. This will improve the adaptability and employability of workers and allow them to meet new challenges and a changing environment. Other projects will aim at preventing long-term sickness leave and combating discrimination in getting and advancing in a job.

Priority 2: Increased labour supply Here the focus is on people outside of the labour market, with a focus on young, immigrants and those on long-term sickness leave. The aim is to get them into work or through education or other measures bring them closer to getting a job. ERDF Stockholm (approval date 2007-08-16) The overall objective of the Operational Programme is to strengthen the international competitiveness of the Stockholm region. It will focus mainly on small and medium sized enterprises and increased cooperation between the industrial sector, the research sector and the public sector. The Programme will support entrepreneurship, stimulate innovation and increase the integration of immigrants. Priority 1: Development of innovative environments in the urban area The aim of the priority is to assist in knowledge development, commercialization of goods and services internally and for export, make use of the competence of the whole population, support energy and resource effectiveness.

Priority 2: Business development

103

The aim of the priority is to provide information, training and counselling for SMEs and entrepreneurs, as well financial engineering and access to capital. In this context, both JEREMIE and JESSICA are seen as interesting possibilities.

Priority 3: Accessibility The aim is to improve the accessibility of the larger Stockholm region, assure housing and transportation to meet the population growth, improve co-operation with regions beyond the Stockholm region and improve co-ordination between different types of public and goods transportation.

Priority 4: Technical assistance The aim is to support the operational programme.

We have mainly had actions that are indirectly liked to health and quality of life. Health as such is not a priority in the Operational Programmes and we have mainly uses local and national funding for health projects.

In the social fund we are active in three projects: - ‘Language development and language environments at workplaces’ in the elderly care. - ‘Carpe’; analysing the needs of competence for staff caring for disabled. - ‘Internal movements’ to decrease sickness leave as well as employment turnover and increase full-time employment.

We are also in discussions about other projects in the social fund and one in the regional fund focusing mainly on the elderly care sector and within the work with immigrants.

National funded project has been developed the past years. For example; - Develop the work with diets and nutrition in the elderly care - Together with NGO’s develop the social dimension among elderly - Inform 80+ about the possibilities to prevent ill-health - Increase knowledge about dementia diseases among care staff and relatives - New ways of competence improvement for staff working in the elderly care - Nature conservation to improve the pasture land, enlarg a nature reserve and to improve paths for outdoor life. - Building new and improve existing cycle ways - Modifying bus stops to give better access for disabled persons

The main challenge is that health are not prioritized in the regional Operational Programs. However, there are indirect links between local health-related actions and the OP e.g. to develop relevant skills among the staff in the elderly care and to analyze the needs to give relevant training. Also, the unemployment rate is low in Lidingö but there are still some people having problems finding employment and the OP can support our work for people outside the labour market. Putting health in a socio-economic context makes this important. Another challenge is that the OP´s are prioritizing big strategic projects. It can be a challenge for a small department in the city to have a leading role in such a project. But, this can also be a good opportunity to exchange knowledge and to co-operate with relevant stakeholders in the region.

Sources

Statistics Sweden (Statistiska Centralbyrån) www.scb.se

104

Public Health Report 2007 , Stockholm Center for Public Health (Folkhälsorapport 2007, Centrum för folkhälsa) www.folkhälsoguiden.se

Public Health in Regional Development Planning , The Office of Regional Planning and Urban Transportation (Folkhälsa i regional utvecklingsplanering, Regionplane- och trafikkontoret) 2008

Health Impact Assessment – report from a development process . Project Report, Stockholm County Council 2008 (Hälsokonsekvensbedömning – beskrivning av ett utvecklingsarbete, projektrapport, Stockholms läns landsting 2008)

Health Strategy , City of Lidingö 2006 (Lidingö stads hälsoprofil –strategi, mål och riktning)

Community Report on the Citizens’ Health Status , City of Lidingö 2005 (Hur mår Lidingö? Samhällsanalys 2005)

Lifestyles of Youths in Lidingö , Ulf Blomdahl 2007 (Ung livsstil på Lidingö Ht 2007)

Structural Funds , Nutek www.nutek.se

Social Fund , ESF-rådet www.esf.se

105

Łodz - Poland

Magdalena Affeltowicz Lodz City Office - Department of Public Health 24 July 2008

General socio-economic context: current situation and main issues related to health

Lodz – the third largest city in Poland is situated in the centre of the country, about 100 km from the capital – Warsaw. Its population (as of 31 December 2007) is 753 192 with 410 641 women (54.5%) and 342 551 men (45,5%). For over 15 years Lodz has been experiencing gradual decrease in population with the natural increase per 1000 population –6.5 in 2006. Although Lodz is an important academic centre, the level of education of its residents is relatively low. According to the results of the national census in 2002 14.6% of them had tertiary, 39.6% secondary or post-secondary, 16.5% basic vocational and 23.8% primary education. 1.9% of the population did not complete primary school or had no school education and the level of education of 3.6% residents was unknown. Lodz is an aging city. In December 2007 the population aged 0-17 years was 106 712 54 918 males, 51 797 females), 18-64 years – 519 009 (245 092 males and 273 917 females) and 65+ 127 471 (42 541 males and 84 930 females). It is estimated that in 2030 the proportion of men over 65 and women over 60 will reach 27.8% in the Lodz region. It will be the highest rate in Poland. Until the transformation of the 1990s Lodz had been primarily an industrial city, the so-called “city of working women”. Since then the state-owned textile industry has collapsed. This caused a dramatic increase in unemployment rates in the 1990s and in the first years of the 21 st century, which reached the level of over 18%. The situation on the labour market started to improve after 2004 when Poland became a member of the EU. This is due to the increased emigration of Lodz residents to countries which opened their labour markets to Poland and to the development of small private businesses and growing interest of investors in our city. As a result the unemployment rate in Lodz in March 2008 was 8.4%. Although it is lower than the Polish average (10.5%), it is still higher than in other big cities in Poland (2.9% in Warsaw, 2.2% in Poznan. 3.9% in Krakow). The standards of living in Lodz are relatively low, which is due to low incomes of the inhabitants In 2006 the average monthly salary in Lodz in the enterprise sector was by 33,9% lower than in Warsaw, by 18% lower than in Poznan, by 9.9% lower than in Krakow and 9% lower than in Wroclaw. One of the indicators of health status of the inhabitants is life expectancy at birth which in Lodz is lower than the average for Polish urban communities (for men 68.24 vs. 71.17, for women 78,07 vs. 79.49 in 2006). Mortality due to neoplastic diseases in 2005 in Lodz was 32.02, and due to cardiovascular diseases 55.86 per 10 000 inhabitants. A survey carried out in late 2006 in the framework of a EU project HEPRO (“Focus on health and social well-being in the Baltic Sea Region”) showed that the lifestyle of the residents of Lodz is far from healthy: 40% of them prefer passive forms of spending their free time (such as reading or watching TV) and 32% of them are daily smokers. The relatively poor economic and health status of the residents is reflected in their sense of well- being. 4.7% of them perceive their health as very bad (cf. the Polish average 2.1%), 29.1% complain of stress in everyday life (cf. 17.4% in Warsaw, 22.4% in Olsztyn and 26,0 in

106

Poznan), 7.5% experience strong feelings of hopelessness (cf. 2.2% in Warsaw, 4.3% in Olsztyn and 5.4% in Poznan).

Theme 1: Health Impact Assessment (HIA) and the use of urban health indicators

Health Impact Assessment is one of the core themes of Phase IV of the WHO Healthy Cities Project (2003-2008). Lodz, as a member of the Healthy Cities Project Network organized a training for beginners for representatives of several member cities in March 2006. The course, conducted by a HIA practitioner from the UK, Erica Ison was attended by two workers of the City Department of Public Health, who also took part in the meeting and training course for the HIA Subnetwork of the Healthy cities Project in Geneva in April 2008. The HIA procedure has never been used on any proposals in Lodz and the city authorities are not familiar with its methodology.

Wojewódzkie Centrum Zdrowia Publicznego (Regional Public Health Centre) collects health indicators for the region every year and publishes them in the form of a booklet under the following headings: demographic data, health status of the inhabitants, health care personnel, outpatient care, mother and child care, in-patient care. The statistics include also certain information for the city of Lodz. These, however, are mainly focused on the incidence of the most common diseases, mortality and health care provision. A somewhat wider approach is taken in the collection of indicators for WHO Healthy Cities Project, which takes place when the city is applying for the successive phases of the project (approximately every five years since 1993). These include general data on the city (demography), health indicators (mortality due to all causes with age-group breakdown, mortality due to specific causes, low birth weight) indicators referring to health care (number of city residents per one GP and per 1 nurse, percentage of vaccinated children, number of miscarriages), indicators connected with the quality of the environment (air pollution, water quality, waste management, household waste collection, area of green spaces in the city, public access to green spaces, length of pedestrian streets and cycle paths, public transport services) and socio-economic indicators (percentage of inhabitants living in poor quality housing, percentage of inhabitants who use social welfare services, number of places in pre-school facilities, percentage of live births by mothers’ age groups) Data which are more life-style oriented were collected during a survey on a representative group of 1000 adult Lodz residents, conducted in 2006. The respondents were asked about their age and education level and economic status which allows to analyse the results with respect to these factors. The information collected includes the respondents’ own perception of their health status, stress in everyday life, presence of chronic health problems and their influence on everyday activity of the respondents, the frequency with which they experience fear, worry, hopelessness, sadness, tiredness or feel full of energy. The inhabitants were also asked about diseases from which they suffer currently or suffered in the past, their use of health services, and medication taken. The survey included questions on the lifestyle of the residents: smoking, alcohol use, physical activity, BMI and the importance of reducing the negative habits. The respondents expressed their opinions on the safety of their neighbourhood, the level of noise, air pollution and the quality of services (public transport, post office, banks, shops etc.) and accessibility of sports and leisure facilities, theatres, cinemas, libraries, clubs and parks. They were asked about their confidence in different public institutions, such as health service, the police, local government, the media, judicial system or social welfare system.

Due to new financial possibilities resulting from the membership in EU, the city of Lodz is undergoing major changes. Many projects which are directly or indirectly connected with health are being implemented, such as the development of the local airport, the building of the regional

107

tram line, residential areas and hotels are being built, big shopping centres appear. This is one of the reasons why Health Impact Assessment methodology should be introduced in the city to determine all the possible impacts of these projects on the health determinants and consequently on the health of the citizens, as well as minimize the possible negative effects. HIA and its benefits should be presented to the decision makers in the city and cooperation should be established with cities who have experience in HIA and independent institutions specializing in its methodology. We expect to continue work on the questionnaire which served as a tool to collect the data on the health of the inhabitants and to repeat the survey on the health status, lifestyle and perceived health of the residents of Lodz at 5-year intervals.

Theme 2: Policies and actions for an active and healthy ageing

The population of Lodz aged 65 years or over is 127 471 (16.9% of the total city population) - 42 541 males and 84 930 females). It is a very diverse group including people working for NGOs and living an active life and people who suffer from poor health, social exclusion and spend the late years of their lives in a passive way. Supporting this part of the city population is one of the priorities of Lodz Healthy City Project. The basic form of action in this field is cooperation with NGOs, such as the Third Age Universities (there are three organizations of this type in Lodz), or the Union of Senior Citizens. The City Department of Public Health finances also health education for the elderly conducted in the day care centres. For several years grant competitions have been organized by the city to support action addressed to the older residents of Lodz. This stimulated other NGOs, such as the catholic charity Caritas or the Lodz Unit of the Polish Tourist Association, to undertake action in this field. In order to collect more information on the lifestyles and behaviours of the elderly population of Lodz, two surveys have been carried out. One of them was addressed to the listeners of the Third Age Universities and the clients of day care centres. The other, which included a representative group of 420 residents of Lodz aged 65+, was co-financed by the City Department of Public Health and carried out by researchers of the University of Lodz. The results showed that the elderly inhabitants of the city spend most of their time cooking, cleaning their homes and shopping. 22% of them look after their grandchildren. They spend most of the remaining time watching TV. Only 4% of them take part in the activities organized by the Third Age Universities, and 3% attend clubs for senior citizens. Only a half of the respondents went away on holiday within two years before the survey. 90% of these did not leave Poland. The reported reason for not leaving the city was usually poor health or lack of money as the. 70% of the respondents help their friends, relatives and neighbours, and 57% receive help from others. 23% declare they do not need any form of help or support. 30% of the respondents perceive their health as poor or very poor. They look after their health by visiting doctors, and following their orders (82%) not smoking (72%), refraining from drinking alcohol or going for walks (58%). Their most common health problems are: cardiovascular diseases and locomotor system disorders. 30% of the respondents admit that they have just enough money to satisfy their basic needs, and 8% have problems even with that. In the opinion of the respondents old age is associated with loneliness and deterioration of health, and for very few of them it means stability, quiet life and having more free time. In spite of this 82% of them are satisfied with their life. They believe that health is the most important asset in life.

The surveys showed that city action addressed to the elderly population is not sufficient because it gets across to only a very narrow group of most active senior citizens. The lack of personal activity in later years of life often results from life-long habits and lack of models of active aging. The elderly are not aware of activities offered to them by different organizations and do not know where to turn for help when they need it.

108

The organizations which address their action to the elderly population often mention problems with getting their messages across to their target group. They also lack professional personnel to work with the elderly people due to limited funds. It is necessary to develop a strategy which would bring about a change in the common model of aging and promote more active lifestyles. The city should stimulate NGOs to work on programmes for the elderly which will create more possibilities of active living for the elderly inhabitants.

Theme 3: Healthy Places and Healthy Environment

Due to the collapse of industry in Lodz, the quality of the environment in the city has improved during the last decade. Non-industrial sources of pollution have therefore become more important. The main source of noise in the city is the traffic (cars, trams, buses and – especially in the northern part of the city centre – the railway). This results from low technical condition of the vehicles and the road surface, as well as the old, compact patterns of land development with narrow streets. 40% of the inhabitants complain of high level of noise in their neighbourhood. Traffic, power plants and households using coal heating are sources of the majority of atmosphere pollution in the city, which especially in the cold season of the year exceeds permissible levels in some parts of the city (sulphur dioxide and dust). 44% of the city residents complain of air pollution in their neighbourhood. The sanitary condition of the city is poor primarily due to the attitudes of the inhabitants who do not take care of cleanliness of public places. Soils in Lodz are mostly degraded, with high level of acidity, zinc, cadmium and lead. Taking all the above into consideration, the influence of the city environment on the health of the inhabitants is negative. A positive aspect of the environment in Lodz is that the city has 35 parks (total surface 5 300 000 square metres), many green spaces, cemeteries and within its limits in the north a large forest is localized (12 000 000 square metres). 42% of the city residents visit parks and green spaces at least once a week, and further 20% at least once a month. Most of the parks localized in the centre of the city require revitalization due to poor condition of the soil). The programme of revitalization of parks was first introduced in 1996 and has been continued since then.

The quality of the city environment has a strong impact on the health and sense of well being of the inhabitants. Therefore the city has undertaken a number of steps to improve its condition. One of the most important projects was the construction of water waste treatment plant, which took over 20 years and was completed in 2006. It has an influence on the environment not only in Lodz, but also in the region and has contributed to revitalization of the river Ner. Another project is the communal waste management project in Lodz which will result in increased amounts of recycled waste and reduced amount of the waste deposited in the city dump. The capacity of the plant is 82 500 tons per year. The project includes also promotion of household waste separation among the inhabitants and creation of a green belt around treatment plants. Waste separation programme has been promoted in Lodz since 1994. In 2008 a local law was introduced which obliges the inhabitants to separate waste at the household. The water supply network and sewage system in the city is currently being modernized. This project will eventually be carried out along 700 streets in Lodz (78 streets in 2008). As a result the number of inhabitants who can use the sewage system will increase by 40 000. A large project entitled Lodz Regional Tram was started in Lodz in 2007 and completed in June 2008. It involved modernization of a tram line which runs through the whole city on the north- south axis and joins it with the neighbouring town of Zgierz. The length of the line is 27 km and

109

the results of the project include reduction of emission of harmful gases and dust due to reduced motor traffic, reduction of noise, improvement of comfort of public transport and better access to public transport by the elderly and disabled people. The expected increase in the number of passengers using public transport is 20%. In order to reduce traffic related pollution and at the same time promote physical activity among the residents a system of cycle paths is being built. So far the length of all cycle paths in the city is 11.5 km, but it is expected that by the year 2020 their length will be 250 km. An acoustic map of the city has been developed which will allow to determine the level of noise pollution in its different parts and reduce the intensity of noise in the future.

Although the centre of the city is its most cramped part, and the people who live or work there suffer from traffic noise and air pollution, it is hard to select one area in Lodz that is particularly unhealthy, because city infrastructure in other parts of the city are more neglected. Therefore it would be more advisable to work out a strategy for the whole city to reduce the adverse effects of the city environment on health and well being of the inhabitants. This could include reduction of road traffic, by promoting public transport and further improvement of its quality, promoting the use of bicycles. Further revitalisation of the older buildings will also improve the quality of life in Lodz. Efforts should also be made to improve sanitary conditions in some streets of Lodz (some of them very close to the centre of the city) where the buildings are not connected to the city sewage system.

Theme 4: Use of Structural Funds in designing actions to develop "health gains"

In the period 2007-2013 the body responsible for managing the majority of structural funds in the region is the regional government(Marszalek Wojewodztwa Lodzkiego) who is the managing authority for the Regional Operational Programme (ROP) for the Lodz Region for the years 2007-2013, co-financed from ERDF, including the following priorities: 1. transport infrastructure, 2. environmental protection, 3. economy, innovativeness and entrepreneurship 4. information society, 5. social infrastructure, 6. revitalization of urban areas, The final version of ROP was approved in October 2007. A list of key projects was collected at the beginning of 2007. Other projects will apply for funds in competitions announced by the regional managing authority. The same authority acts as intermediate body for several priorities of Operational Programme Human Capital co-financed from European Social Fund. It has delegated some of its responsibilities in this area to its agencies, such as the Regional Centre for Social Policy or the Regional Employment Office. Other Operational Programmes co-financed from ERDF or Cohesion Fund (Infrastructure and Environment and Innovative Economy) are managed centrally, although local authorities, ngos, research institutes, universities, medical centres and enterprises are potential beneficiaries The expenditures are qualified as eligible starting from 2007.

Before 2004 when Poland became a member of EU, the city and other organizations localized in Lodz used the so-called pre accession funds (PHARE) to buy computer equipment for schools in the city, to implement projects of social inclusion and to reduce unemployment. In the period 2004-2006 a number of projects co-financed by Structural Funds related to the health and quality of life of the inhabitants were implemented by the city, its agencies and other organizations in Lodz. Some of them were investments in the city infrastructure, such as the above mentioned Regional Tram, revitalization of older parts of the city, modernization of main roads and streets. Apart from these ERDF was used to establish an electronic system which facilitates contacts of the residents with the local authority (on-line communication), to modernize hospitals, including renovation of the buildings and purchase of modern medical

110

equipment, the purchase of ambulances for the regional ambulance service, to develop IT technologies or to modernize buildings and purchase equipment for public and private universities. Within the framework of INTERREG a project was implemented to examine the health status and perception of health of the residents of Lodz (the above mentioned HEPRO project). ESF was used to provide grants for students in the most disadvantaged financial situation in order to promote secondary and tertiary education, to organize foreign language courses and training courses for the unemployed, which allow them to gain new skills and qualifications and to encourage and instruct them how to launch their own businesses. A number of projects were implemented to support the development of small and medium private enterprises. ESF funds were also granted to a number of NGOs working in the city which served the purpose of activating the local community, developing environment-friendly attitudes or helping children and youth from dysfunctional families.

Cohesion Fund was used to finish the construction of waste water treatment plant and build a modern solid waste treatment plant as well as modernize the city water supply network EOG resources were used by the Institute of Polish Mother’s Health Centre in Lodz , which is supervised by the Ministry of Health, to introduce the system of on-line registration of patients. Research and academic centres used funds of the 6 Framework Programme to carry out their scientific projects.

The main needs for action to address problems of health and quality of life include: 1. Intensified action in the field of health promotion and prevention of chronic diseases 2. Improvement of health care infrastructure to meet the standards required in EU countries and improve access to health services and thus promote equity in health 3. Further improvement of city infrastructure – roads, public transport, wheelchair accessibility of public buildings, 4. Revitalization of degraded city areas, often of historical value. 5. Investment in existing cultural and sports facilities. 6. Supporting community groups in order to increase community participation and build civic society 7. Development of the tourist infrastructure, which may result in increased employment and consequently – improved standard of living in the city.

Other comments

The specific problems in using structural funds in Lodz are the problems shared by all potential beneficiaries in Poland. They mostly result from a very short experience of Polish organizations and institutions in applying for EU funds. Another obstacle are very difficult national procedures concerning public funds, or procedures required in individual organizations, which are often less flexible than and not always consistent with European regulations. There is also a problem of inadequate competence and skills of the officials in managing authorities or intermediate bodies due to fluctuation of personnel.

Sources

“Perspektywy demograficzne województwa łódzkiego”, Urz ąd Statystyczny w Łodzi, Łód ź 2005 „Statystyka Łodzi”, Urz ąd Statystyczny w Łodzi, Łód ź 2006 „Informator Statystyczny Ochrony Zdrowia Województwa Łódzkiego 2006” Wojewódzkie

111

Centrum Zdrowia Publicznego w Łodzi, Łód ź 2007 ”Analiza stanu środowiska” , dr in Ŝ. Halina Jaroszewska, dr in Ŝ. Arch. Barbara Wycichowska, http://www15.uml.lodz.pl/prorevita/ „Raport z badania w ramach projektu Orientacja na zdrowie i dobrostan społeczny w Regionie Morza Bałtyckiego/ HEPRO ”, dr Jacek Py Ŝalski, mgr Eliza Iwanowicz, mgr Patrycja Wojtaszczyk, Łód ź, czerwiec 2007. „Razem dla zdrowia” – conference materials of the IV Lodz Healthy City Forum, 2006. www.lodzrowerowa.pl Raport z bada ń – Styl Ŝycia starszych mieszka ńców Łodzi, Patrycja Woszczyk, Łód ź, 2007. ”Sytuacja społeczno-ekonomiczna w Łodzi 2006 rok” Wydział Strategii i Analiz, Urz ąd Miasta Łodzi, Łód ź, 2007. ”Biuletyn Statystyczny Miasta Krokowa”, http://www.bip.krakow.pl ”Ludno ść Łodzi i innych wielkich miast w Polsce w latach 1984-2006” Włodzimierz Obraniak, Urz ąd Statystyczny w lodzi, Łód ź, 2007. http://www.stat.gov.pl/urzedy/lodz

112

Madrid - Spain

Ana Isabel López Valero, Beatriz Blanco García Ayuntamiento de Madrid - Área de Gobierno de Urbanismo y Vivienda, Dirección General de la Oficina del Centro July 2008

General socio-economic context: current situation and main issues related to health

The birth rate in the City of Madrid is especially low, although it is increasing due to the growing presence of the immigrant population. Currently, at least one in every five residents of Madrid is foreign. Aging is very important, and one of every three people 75 and over lives alone. Likewise, an elevated level of demographic dependence is seen: there is one dependent for every two people. (Source: Study of Health in the City of Madrid. Madrid Health. Madrid City Government)

Surface area, population and density of the Districts of the City of Madrid as of 1.1.2007 Districts Surface area Population Density (Inh/Ha) Total 60,430.8 3,187,062 52.7 1. Centro 523.1 141,396 270.3 2. Arganzuela 648.1 149,577 230.8 3. Retiro 545.1 124,530 228.4 4. Salamanca 538.7 146,763 272.4 5. Chamartin 917.0 143,778 156.8 6. Tetuan 538.8 152,206 282.5 7. Chamberi 467.4 145,593 311.5 8. Fuencarral-El Pardo 23,781.0 212,710 8.9 9. Moncloa-Aravaca 4,653.1 117,356 25.2 10. Latina 2,541.6 256,644 101.0 11. Carabanchel 1,404.8 248,350 176.8 12. Usera 775.5 136,391 175.9 13. Puente de Vallecas 1,500.6 241,907 161.2 14. Moratalaz 611.0 104,923 171.7 15. Ciudad Lineal 1,142.6 226,805 198.5 16. Hortaleza 2,741.5 161,661 59.0 17. Villaverde 2,013.4 146,184 72.6 18. Villa de Vallecas 5,142.1 67,163 13.1 19. Vicalvaro 3,517.7 66,299 18.8 20. San Blas 2,236.8 153,128 68.5 21. Barajas 4,190.8 43,698 10.4

Evolution of the de jure population Referen De jure Intercensal Growth rate Natural Net migration rate ce Date population (1) growth (2) growth 1900 540,109 - - - 1910 556,958 16,849 0.31 13,774 3,075 1920 728,937 171,979 3,09 60,344 111,635

1930 863,958 135,021 1.85 75,558 59,463 1940 1,096,466 232,508 2.69 ... .. 1950 1,527,894 431,428 3.93 431,428

1960 2,177,123 649,229 4.25 338,210 311,019 1970 3,120,941 943,818 4.34 661,348 282,470

113

1981 3,158,818 37,877 0.11 232,356 -194,479

1991 3,010,492 -148,326 -0.47 -82,961 -65,365 2001 2,938,723 -71,769 -0.24 1,961 -73,730 2004 3,182,138 243,415 2.76 6,560 236,855 2006 3,187,062 4,924 0.08 .. .. (1) From 1990 to 1950 the population is that which corresponds to the city limits before the annexation of peripheral suburbs. (2) Annual mean SOURCE: National Institute of Statistics. Population census and official population figures (Ongoing Municipal Register of Inhabitants) since 1998.

Natural movement of the population (Birth, death and marriage) Years Births Birth Deaths Death Rate Marriages Marriage Rate Rate 1996 24,687 8.60 25,662 8.94 14,628 5.10 1997 25,260 8.74 24,922 8.63 14,262 4.94 1998 24,601 8.48 26,236 9.04 14,928 5.15 1999 26,023 8.96 26,412 9.09 15,162 5.22 2000 28,022 9.52 26.061 8.85 15,759 5.35 2001 29,603 9.82 26,164 8.68 15,375 5.10 2002 31,005 10.05 26,521 8.60 15,262 4.95 2003 32,333 10.29 27,654 8.80 14,889 4.73 2004 32,851 10,38 26,527 8.38 15,077 4.76 2005 32,407 10.17 27,056 8.49 14,195 4.45 SOURCE: National Institute of Statistics. "Natural Movement of the Spanish Population". Institute of Statistics of the Community of Madrid: Natural Movement Statistics of the Population

114

Deaths by sex and cause of death in 2005 Rest of causes Female 2,657 Male 2,154 Symptoms, signs, ill-defined conditions of morbidity Female 500 Male 551 Diseases of the digestive system Female 690 Male 692 Diseases of the respiratory system Female 2,031 Male 2,236 Tumours Female 3,152 Male 4,430 Diseases of the circulatory system Female 4,577 Male 3,386 SOURCE: National Institute of Statistics. "Natural Movement of the Spanish Population". Institute of Statistics of the Community of Madrid: Natural Movement Statistics of the Population

De jure population by District, age group and sex as of 1 January 2007 Districts Total Male Female 0-14 15-29 30-44 45-59 60-74 75+ Unkn own Total 3,187,062 1,499,1 1,687,8 41,,5 590,1 840,2 582,7 460,8 301,4 45 76 86 37 48 52 82 05 93 1. Centro 141,396 68,978 72,418 12,70 25,86 46,42 26,09 16,11 14,18 1 9 6 8 8 1 3 2. Arganzuela 149,577 69,576 80,001 18,44 27,18 40,99 31,00 18,23 13,70 5 7 2 9 00 8 6 3. Retiro 124,530 56,625 67,905 14,41 21,95 28,91 25,90 19,63 13,70 2 1 2 6 5 8 6 4. Salamanca 146,763 64,304 82,459 16,20 24,44 26,10 28,67 22,59 18,74 5 6 1 5 4 2 0 5. Chamartin 143,778 64,564 79,214 18,49 24,38 34,79 28,34 22,03 15,71 4 0 6 7 6 7 8 6. Tetuan 152,206 69,389 82,817 16,79 28,45 41,05 27,76 21,00 17,13 2 9 3 3 7 1 1 7. Chamberi 145,593 62,936 82,657 14,72 25,14 35,21 28,78 22,05 19,66 2 8 3 0 3 9 8 8. Fuencarral-El 212,710 100,43 112,27 28,37 40,96 50,80 43,16 33,02 16,37 2 Pardo 9 1 5 4 0 9 3 7 9. Moncloa- 117,356 53,683 63,673 16,47 20,65 28,68 23,35 16,77 11,40 7 Aravaca 6 2 2 7 5 7 1 Latina 256,644 122,42 134,22 29,07 48,33 65,30 43,37 45,71 24,83 1 0. 4 0 6 5 7 5 8 2 1 Carabanchel 248,350 118,74 129,60 31,63 48,14 67,78 40,85 36,01 23,63 3 1. 1 9 5 9 7 1 7 8 1 Usera 136,391 65,506 70,885 19,12 27,04 37,67 21,83 17,60 13,10 0 2. 1 4 6 9 8 3 1 Pte de 241,907 117,03 124,86 34,03 48,82 63,56 41,84 31,64 21,99 1 3. Vallecas 9 8 1 9 0 9 7 0 1 Moratalaz 104.923 49,441 55,482 13,93 18,17 26,12 18,43 18,60 9,649 1 4. 3 8 0 3 9 1 Ciudad Lineal 226,805 104,74 122,06 28,69 4029 2711 4161 3546 2362 5 5. 0 5 5 3 2 2 1 7 1 Hortaleza 161,661 77,283 84,378 24,16 29,61 42,25 31,43 23,49 10,69 2 6. 3 0 9 2 6 9 1 Villaverde 146,184 71,928 74,256 21,66 29,28 41,56 22,54 20,34 10,76 0 7. 9 8 6 9 8 4 1 Villa de 67,163 32,940 34,223 10,32 14,76 17,55 12,95 7,807 3,752 0 8. Vallecas 3 9 5 7 1 Vicalvaro 66,299 32,852 33,447 11,65 1184 2194 9,872 7,881 3,104 1

115

9. 5 6 0 2 San Blas 153,128 74,242 78,886 23,62 26,25 43,83 26,49 19,30 13,62 1 0. 0 1 0 9 5 2 2 Barajas 43,698 21,546 22,152 6,975 8,247 12,55 8,415 5,434 2,077 0 1. 0 SOURCE: Spanish Department of Treasury and Public Administration. Directorate-General of Statistics.

Population by District and Nationality as of 1 January 2007 Nationality % Districts Total Spain Other country foreigners Total 3,187,062 2,680,830 505,572 15.9 1. City Centre 141,396 104,131 37,232 26.3 2. Arganzuela 149,577 126,382 23,164 15.5 3. Retiro 124,530 112,986 11,518 9.2 4. Salamanca 146,763 127,387 19,332 13.2 5. Chamartin 143,778 127,288 16,432 11.4 6. Tetuan 152,206 121,107 31,063 20.4 7. Chamberi 145,593 125,337 20,198 13.9 8. Fuencarral-El 212,710 199,000 29,688 9.2 Pardo 9. Moncloa- 117,356 102,766 14,550 12.4 Aravaca 10. Latina 256,644 212,026 44,573 17.4 11. Carabanchel 248,350 194,513 53,810 21.7 12. Usera 136,391 106,745 29,623 21.7 13. Puente de 241,907 199,310 42,563 17.6 Vallecas 14. Moratalaz 104,923 94,513 10,401 9.9 15. Ciudad Lineal 226,805 189,012 37,723 16.6 16. Hortaleza 161,661 143,811 17,815 11.0 17. Villaverde 146,184 115,070 31,101 21.3 18. Villa de 67,163 57,069 10,090 15.0 Vallecas 19. Vicalvaro 66,299 56,735 9,557 14.4 20. San Blas 153,128 132,931 20,182 13.2 21. Barajas 43,698 38,711 4,977 11.4 SOURCE: Spanish Department of Treasury and Public Administration. Directorate-General of Statistics.

Evolution of the number of foreigners in the city of Madrid (SOURCE: Spanish Department of Treasury and Public Administration. Directorate-General of Statistics) January 00 100,163 January 01 194,297 January 02 286,440 January 03 362,155 January 04 427,692 January 05 452,616 January 06 507,054 January 07 505,572

Increase in population by nationality in 2006 Geographic-economic area Forei gners Inc rease 2006 2007 Absolute % TOTAL 507,0543 505,572 -1,482 -0.3 EUROPEAN UNION (25) 43,809 51,218 7,409 16.9

116

Italy 9,111 10,995 1,884 20.7 Poland 7,696 8,905 1,209 15.7 France 7,628 8,722 1,094 14.3 Portugal 5,633 6,832 1,199 21.3 Germany 4,299 4,926 627 14.6 United Kingdom 4,118 4,568 450 10.9 Other E.U. countries 5,324 6,270 946 17.8 REST OF EUROPE 61,610 70,614 9,004 14.6 Romania 37,816 46,218 8.402 22.2 Bulgaria 10,819 11,379 560 5.2 Ukraine 7,023 7,178 155 2.2 Other European countries 5,952 5,839 -113 -1.9 NORTH AMERICA 10,729 9,382 -1,347 -12.6 Mexico 5,445 4,641 -804 -14.8 United States 4,927 4,457 -470 -9.5 Canada 357 284 -73 -20.4 CENTRAL AMERICA 28,689 28,223 -466 -1.6 Dominican Republic 19,428 19,069 -359 -1.8 Cuba 6,186 5,308 -878 -14.2 Other Central American countries 3,075 3,846 771 25.1 SOUTH AMERICA 279,964 269,511 -10,453 -3.7 Ecuador 132,719 111,154 -21,565 -16.2 Bolivia 26,383 38,338 11,955 45.3 Columbia 43,883 37,548 -6,345 -14.5 Peru 32,268 32,709 441 1.4 Brazil 10,047 13,049 3,002 29.9 Paraguay 6,610 11,599 4,989 75.5 Argentina 12,674 10,576 -2,098 -16.6 Venezuela 8.022 7,892 -130 -1.6 Other South American countries 7,358 6,656 -702 -9.5 ASIA 39,476 37,471 -2,005 -5.1 China 22,228 21,439 -789 -3.5 Philippines 7,432 6,904 -528 -7.1 Bangladesh 2,538 2,647 99 3.9 Japan 1,092 985 -107 -9.8 Other countries in Asia 6,176 5,496 -680 -11.0 AFRICA 42,413 38,857 -3,556 -8.4 Morocco 26,483 23,881 -2,602 -9.8 Nigeria 2,637 2,190 -447 -17.0 Mali 1,393 1,846 453 32.5 Senegal 1,626 1,631 5 0.3 Equatorial Guinea 1,725 1,415 -310 -18.0 Other countries in Africa 8,549 7,894 -655 -7.7 OCEANIA 255 233 -22 -8.6 STATELESS 108 63 -45 -41.7 SOURCE: Directorate-General of Statistics. Municipal Register of Inhabitants.

The immigrant phenomenon in the city is intense. At the beginning of 2006, there were more than a half million registered foreigners living in Madrid, representing nearly 17% of the population. This presence is noticeably greater than in the country overall, where it is less than 10%, and its distribution within the city is unequal. They tend to concentrate above all in certain areas of the city centre, and in the southern and eastern parts of the city. There are neighbourhoods in these areas where their percentage of the overall population exceeds 35%. As immigrants are a population with health-related factors that are different to the rest of the residents, it is very important to observe the evolution of their geographic location within the city because this information can be useful when planning resources. There are districts where growth is due exclusively to the foreign population. (Source: Study on health in the City of Madrid. Madrid Health. Madrid City Government)

117

Survey of Active Population 2006 Relation with the activity (in thousands) Active Population Unemployed Quarter Population Total Employed Total Have worked Looking for older than 16 before 1st job years 1st Quarter 2,683.6 1,612.5 1,521.0 91.6 5.9 85.7 2nd Quarter 2,660.7 1,632.2 1,525.8 106.4 11.5 95.0 3rd Quarter 2,681.1 1,634.0 1,545.3 88.7 14.1 74.5 3rd Quarter 2,688.9 1,660.5 1,557.3 103.2 11.8 91.3

Percentage of Employed by Economic Sector. Fourth quarter, 2006 Services: 79.5% Agriculture: 2.5% Industry: 9.0% Construction: 9.0%

Activity, employment and unemployment rates by sex and age group (%) Year/ Activit Rate Employme Rate Unemployme Rat y nt nt e Quarte 1st 2nd 3rd 4th 1st 2nd 3rd 4th 1st 2nd 3rd 4th r

Total 60.09 61.3 60.9 61.7 56.68 57.3 57.6 57.9 5.68 6.52 5.43 6.2 4 4 5 4 4 2 1

Males 68.34 70.0 69.7 70.2 64.78 66.2 67.2 66.6 5.22 5.44 3.59 5.0 9 8 0 8 7 8 1 Female 52.64 53.5 53.1 54.3 49.36 49.3 49.1 50.2 7.85 7.79 7.55 7.5 s 1 8 4 4 7 2 8 16 to 21.84 61.9 86.4 20.6 17.51 55.1 82.1 19.6 19.82 10.9 4.91 5.2 19 9 1 8 9 6 0 7 6 20 to 25.54 62.4 87.9 22.5 14.88 54.6 83.0 21.6 41.74 12.4 5.53 4.0 24 5 0 2 9 4 1 2 5 25 to 24.79 68.0 86.3 21.8 16.78 59.8 82.5 20.9 32.32 11.9 4.33 3.9 54 1 1 5 9 7 8 4 8 55 and 19.91 69.4 88.0 23.0 11.23 61.3 83.2 22.3 43.58 11.7 5.43 2.8 over 7 0 3 0 2 7 7 6 Source: National Institute of Statistics

Employment Rate by Sex and Age Groups. Fourth Quarter 2007

55 and over Female 13.8 Male 34.3 25 -54 Female 77.9 Male 88.7 20-24 Female 59.6 Male 63.2 16-19 Female 3.9 Male 17.5 Source: National Institute of Statistics

118

Evolution of Employed People in the Service Sector by Branches of Activity (in thousands)

I II III IV Other services (1) 500.4 488.1 465.8 489.9

Finances, real estate 337.5 344.8 351.7 364.1 and service companies Transport and 132.3 130.5 129.1 123.6 communication

Business, hotel and 253.2 268.0 289.4 288.1 catering, and repairs (1) Includes Public Administration, Defence and Social Security, Education, Health and Social Services, Personal Services, Homes employing domestic staff and Extraterritorial Organisations

In Madrid, a smaller proportion of people live in poverty than in Spain, and there is a better distribution of wealth as well. This is shown by data such as 2.9% of households in the City of Madrid are living in poverty, while in Spain this number rises to 13.9%, and that the Gini coefficient in this city is 16.5% while in the country as a whole it is 18.9% (the Gini coefficient is a measure of statistical dispersion most prominently used as a measure of inequality of income distribution or inequality of wealth distribution). Despite this, the differences in per capita income among districts are remarkable. The income by district indicator is a good and efficient predictor of health inequalities defined by territory within the city. Nevertheless, unemployment seems to explain the variations in life expectancy better than income and educational level.

The City of Madrid in Data Form-Health care facilities Health care facilities-Beds, People, Stays, Waiting List, expenses and purchases by hospitals for functional dependence in 2006

TOTAL Public Private entitites Specialty Autonomous Community and Non-charitable Charitable Administration Total private private (Church and Beds 12,935 8,322 4,613 3,374 1,239 Total 54,982 41,445 13,537 10,709 2,828 Specialised Management 505 311 194 160 34 personnel personnel Health care 39,615 29.028 10,587 8.253 2,334 personnel No health care 14.862 12.106 2.756 2.296 460 personnel Personnel in training 2,821 2,655 166 146 20 Stays 3,831,428 2,572,678 1,258,75 911,273 347,477 0 Waiting list 17,802 17,417 385 .. .. Purchases and expenses (in 3,426,680 2,670.517 756,163 ...... thousands of

119

Source: Provisional data. Community of Madrid, Dept. of Health. Health Information Services

Care of People 65+/ Home tele-care users by District in 2006 1. Centro 3,497 2. Arganzuela 3,605 3. Retiro 3,103 4. Salamanca 3,800 5. Chamartin 3,061 6. Tetuan 4,287 7. Chamberi 4,106 8. Fuencarral-El Pardo 3,802 9. Moncloa-Aravaca 2,479 10. Latina 6,026 11. Carabanchel 6,861 12. Usera 3,874 13. Puente de Vallecas 6,687 14. Moratalaz 2,792 15. Ciudad Lineal 6,234 16. Hortaleza 2,958 17. Villaverde 2,815 18. Villa de Vallecas 1,156 19. Vicalvaro 890 20. San Blas 4,164 21. Barajas 591

Municipal Health Services-Services provided by the S.A.M.U.R. by year Years TOTAL ALS BLS Civil Protection Psychiatric Other Sched. Serv.

2004 99.419 31,309 48,501 14,412 2,832 1,511 854 2005 108,386 30,940 59,262 12,718 2,706 1,515 1,245 2006 117,223 28,630 64,972 15,507 2,553 3,904 1,657 NOTE: AVS: Transport with "Advanced Life Support" units BLS: Transport with "Basic Life Support" units "Psychiatric": Specialised transport for psychiatric services Sched. Serv. Services previous scheduled for different events. SOURCE: Government Area of Safety and Services to the Community, Directorate-General of Emergencies

People provided services by action programmes in Madrid Health Centres (CMS) TOTAL Infant Adult Over Drugs Vaccinatio Mental Gynecol Social Child 65 n Health ogical Worker 2006 211,748 25,880 64,405 11,403 416 13,176 34,425 60,222 1,821

Arganzuel 15,848 2,078 4,686 1,116 2 1,096 2,277 4,534 9 a Carabanch 18,183 1,581 5,144 770 21 2,568 3,387 4,639 73 el Centro 17,395 1,481 5,571 441 35 867 3,389 5,590 21 C. Lineal 20,098 2,376 6,760 1,670 43 1,346 1,543 6,177 183 Chamberi 13,660 1,345 4,539 348 11 1,212 1,836 4,346 23 Fuencarral 16,433 2,187 4,623 490 65 2,177 3,969 2,922 - Hortaleza 17,598 1,491 6,473 988 43 567 1,702 6,186 148 Latina 6,361 920 1,747 555 58 547 155 2,285 94 Puente de 6,537 1,275 2,836 433 - 57 326 1,376 234 Vallecas Retiro 7,544 982 1,630 597 6 245 1,518 2,514 52 Tetuan 19,463 3,410 5,739 572 48 954 3,685 4,984 71 Villa de 14,290 1,268 4,030 688 25 344 2,815 4,867 253 Vallecas Vicalvaro 19,990 1,364 6,719 909 25 633 5,473 4,708 159

120

Villaverde 18,348 4,122 3,908 1,776 34 563 2,350 5,094 501 Source: Madrid Health. Public Health Institute. Madrid City Government

To a great extent, disadvantages in material and social position determine unhealthy behaviours in our city. In turn, risk-related behaviours appear as the set of causes that has the most effect on the population's level of health. The most important risk factor causing poor health in the City of Madrid is tobacco. Thirteen percent of overall mortality can be attributed to this factor. This means that 10 people die every day in our city as a result of this addiction. With nearly one half of the adult population affected, overweight is starting to be seen as one of the main health problems in this city (about 1.2 million people are in this situation). Also notable are the high frequencies of sedentarism and improper diet, and their greater presence in districts with low per-capital income and high unemployment. (Study of Health in the City of Madrid. Madrid Health. Madrid City Government)

Theme 1: Health Impact Assessment (HIA) and the use of urban health indicators

Over the past several years, the Madrid City Government carried out a health survey (2005), and subsequent to that a study of health in the City of Madrid (2006). This was a "transversal descriptive epidemiological research study seeking to verify relations between variables related to health and other factors that are known scientifically to condition it..." (Source: Study of Health in the City of Madrid 2006. Madrid Health. Madrid City Government)

ASPECTS ADDRESSED 1. STATE OF HEALTH: - Perceived health - Quality of life (WONCA, Kidscreen) - Morbidity risk of mental health disorder (GQH-12) - Dependency (KATZ, LAWTON) 2. MORBIDITY: - Morbidity - Limited activity - Disability 3. CONSUMPTION OF MEDICATIONS: Consumption of medications 4. USE OF HEALTH CARE SERVICES: - Satisfaction with use of H.C. Services. - Satisfaction with use of Municipal Services 5. LEVEL OF SATISFACTION WITH HEALTH CARE SERVICES 6. HABITS AND LIFESTYLES: - Habits and lifestyles - Accidents 7. PREVENTIVE ACTIVITIES: Preventive activities. 8. SCHOLASTIC PERFORMANCE AND OCCUPATIONAL HEALTH: Occupational health

Source: Study of Health in the City of Madrid 2006. Madrid Health. Madrid City Government

Defined below are the indicators used in the Study of Health in the City of Madrid carried out by the Institute of Public Health.

VARIABLES AND INDICATORS USED IN THIS STUDY

121

DEMOGRAPHY • Population structure by age • Aging Index (%) • Youth ratio (%) • Progressivity ratio (%) • Index of Demographic Dependence (%) • Masculinity ratio • Age-specific Fertility Rate (ASFR). • Birth rate • Gross birth rate • Immigration rate • Emigration rate • Natural growth rate • Migratory growth rate • General growth rate • Global fertility rate (GFR) • Synthetic Fertility Index (SFI) or Sum of Reduced Births. • Proportion of population living alone by age (%).

SOCIO-ECONOMICAL ASPECTS • Gross per capita Income Available (GIA). • Mean performance by income tax filer, the indicator's main variable • Percentage of income tax filers relative to the total population • Percentage of income tax filers relative to the population 15 years old or older • Percentage of income declared from sources other than working • Synthetic indicator of socio-economic condition by municipalities • Municipal and regional GDP for the Community of Madrid, 2004 • Poor households in the City of Madrid (%) and poor people in the City of Madrid (%) • Gini coefficient • Engel coefficient • Proportion of people by educational level (%) • Unemployment rate • Proportion of population by type of employment contract • Average number of people per housing unit • Increase in the price of housing in Madrid and Districts in one year • Mean surface area of the housing unit by inhabitant • Number of slum areas in the city and districts and their proportion by number of families • Mean values for different contaminants detected in the air by months in the City of Madrid • Percentile distribution of people personas according to their opinion on noise, the cleanliness of the streets, air quality, street furniture, the upkeep of parks and gardens, public transport, the provision of parks and gardens and health care centres in their district (very poor, poor, average, good or very good): (number of people whose opinion on these aspects of their districts is poor, very poor, average, god or very good)/(total population that has an opinion or not) X 100. • People injured as a result of urban vehicular traffic, by type of victim and age

HEALTH CARE SYSTEM • Proportion of people who are familiar with and have used Madrid Health health prevention and promotion programmes • User satisfaction with Madrid Health Centres regarding different aspects of the care • Activity by the Madrid Health Service (SER+MAS) • Proportion of people by health care coverage level • Proportion of people who have used the health care system in the last two weeks (%)

122

• Proportion of people who have used the health care system in the last twelve months (%) • Proportion of people by the opinion they express about how the public health care system works regarding level of satisfaction • Proportion of people with a less than optimum opinion regarding how the public health care system works in Madrid • Proportion of people over 15 years of age by level of compliance with cardio-vascular prevention programme activities by PAPPS (preventive and health-promoting activities) according to age and sex (%) • Proportion of women over 15 years of age by level of compliance with the women's prevention programme activities according to the PAPPS for their age (%) and other preventive activities • Proportion of people over 16 years of age that properly use safety belts or Child Retention Systems in vehicles, or a helmet on motorcycles • Proportion of minors under 16 years of age that are properly seated in vehicles (%) • Proportion of people older than 16 years of age vaccinated against influenza during the last campaign • Proportion of people older than 16 years of age properly vaccinated against tetanus (%) • Proportion of people by level of knowledge of the official calendar's recommendation for vaccinations (%) • Proportion of minors under the age of 16 by location most often used for vaccination • Proportion of minors under the age of 16 who have received an immunisation not included in the official vaccination calendar. • Proportion of people who have medications in the last two weeks (%) • Proportion of people who have at some time used products derived from alternative therapies (%)

HABITS AND LIFESTYLES • Prevalence rate of sedentarism and low physical activity level • Proportion of people with an adequate intake in terms of quantity and frequency from each food group according to the recommendations of the Spanish Society of Community Nutrition (%) •Proportion of people follow some kind of diet in general, by reason (aesthetic or health) (%) • Average number of hours of sleep per day •Proportion of people by their perception of the adequacy of their hours of rest • Proportion of minors under 16 years of age who watch a lot of television (%) • Proportion of minors under 16 years of age who play with video games or personal computer on a daily basis (%) • Daily average of hours that minors under 16 years of age spend playing with video games or personal computer • Proportion of people according to their status in terms of alcohol consumption (teetotallers or Habitual drinker) • Prevalence rate of drinkers by frequency of consumption • Prevalence rate of smokers in general and by consumption type

SELF-PERCEPTION REGARDING STATE OF HEALTH AND QUALITY OF LIFE • Proportion of people by self-perception of their state of health (%) • Average points obtained from the COOP/WONCA or Kidscreen quality of life questionnaire

LIFE EXPECTANCY • Mean life expectancy at birth • Mean life expectancy at 65 and 75 years of age

123

• Probability of survival at 5 and 60 years of age

HEALTH ADJUSTED LIFE EXPECTANCY • Health adjusted life expectancy (HALE) • Disability adjusted life years (DALY) • Morbidity-free life expectancy (MFLE)

MORTALITY BY AGE • Probability of death by age • Child mortality rate (CMR) • Neonatal mortality rate (NMR) • Early neonatal mortality rate (ENMR) • Late neonatal mortality rate (LNMR) • Post-neonatal mortality rate (PNMR) • Specific mortality rate by age and sex (ASMR)

PROPORTIONAL MORTALITY • Proportion of deaths by cause (%)

RISK OF DEATH • Crude death rate • Adjusted mortality rate (AMR) • Standardised mortality ratio

PREMATURE MORTALITY • Years of potential life lost (YPLL) • Rate of Years of potential life lost (RYPLL) • Adjusted rate of years of potential life lost (ARYPLL)

ATTRIBUTABLE MORTALITY • Mortality attributable to tobacco • Mortality attributable to alcohol

MORBIDITY AND DISABILITY • Estimated rate of chronic disease prevalence • Estimated rate of prevalence of each chronic disease • Estimated rate of prevalence of people with limitations on habitual activity due to a chronic problem • Estimated rate of prevalence of people with limitations on their main activity due to pain or an acute symptom • Rate of prevalence of alterations in the body mass index • Proportion of people with probable non-psychotic poor mental health, depression and anxiety • Proportion of those over 65 years of age in a situation of functional dependency in basic activates of daily living (BADL) or instrumental activities of daily living (IADL) • Proportion of those over 65 years of age with cognitive problems • Accident incidence rate • Induced abortion incidence rate • Induced abortion ratio • Proportion of pregnancies that end in induced abortion • Reportable diseases incidence rate • Tuberculosis incidence rate • AIDS incidence rate

124

• AIDS prevalence rate • Proportion of accumulated AIDS cases by means of transmission and district • Disability prevalence rate

OTHER SYNTHETIC INDICATORS USED IN THE ANALYSIS OF THE INFORMATION Combined index for health, knowledge and income • Mean life expectancy at birth obtained from this same study in 2002 • The percentage of total illiterates by districts for 2004, with data from the Register of Inhabitants and the % of those enrolled in primary and secondary education, obtained from the Directorate-General of Statistics of the Madrid City Government • Gross available income per capita for 2000

OTHERS INDICATORS USED FROM OTHER SOURCES OF INFORMATION CREATED BY THE STUDY

(Source: Study of Health in the City of Madrid. Madrid Health. Madrid City Government)

It is hoped that – by networking and using indicators – a map of indicators can be drawn that will permit assessing the level of health in the communities, so that on the one hand, the aspects that are a threat for the community may be subsequently addressed and, on the other hand, preventive projects can be implemented. It is also hoped that this set of indicators will a level of accuracy and reliability sufficient enough for it to be able to be extrapolatable to any urban space or community.

Theme 2: Policies and actions for an active and healthy ageing

Starting with the premise that ageing is not exclusively linked to illness, dependency and the lack of productivity, the Madrid City Government is especially interested in providing attention to older people, carrying out actions aimed at community development, the promotion of health, the prevention of disease and the improvement in quality of life, creating a framework for action based on "active ageing". Among the activities aimed at older people currently underway we find: - Home assistance services: in-home aide, tele-assistance, meals delivered to the home, laundry services and technical assistance such as articulated bed and age-related adaptations in the home. - Special services: special attention during heat waves, preventive and maintenance physical therapy services, family respite programme, prevention of social isolation... - Municipal programme of physical exercise for older persons - Day and residential centres - Prevention and promotion of health: centres for the prevention of cognitive deterioration, abuse prevention, health education workshops... - Road safety education for older people (road safety plan). - Access to the new technologies for older people: madridmayor.es card - Defence of older people regarding consumption - Encouragement of participation by older people

In terms of the results obtained, analysing the data on attention to and coverage of needs by older people in the City of Madrid, it can be concluded that the level of care and monitoring of this sector of the population is satisfactory in general. Nevertheless, it is necessary on the one hand to reinforce and support certain programmes, and on the

125

other hand, to promote coordinated work with other areas of intervention that also affect the quality of life of older people.

PENDING PRIORITY NEEDS - Encouragement of coordinated and interdisciplinary work - Prevent social isolation by paying special attention to factors that are usually ignored such as influence on psycho-social deterioration, sub-quality housing, overcrowding, architectural barriers, the lack of public space and quality exchange... - Insistence on the development of intergenerational programmes (there are already some underway).

CHANGES TO BE ACHIEVED - More overall and holistic attention and support based on the interaction of the different aspects affecting a health ageing process. - Gain presence in the life of the neighbourhood for the group of older people - Promote the active participation by older people in the development of the neighbourhood - Create mechanisms for making the best use of older people's productivity

Theme 3: Healthy Places and Healthy Environment

MAIN PROBLEMS AND NEEDS IDENTIFIED IN THE CITY - Lack of integrated planning for land use - Serious impact on the natural environment from urban activities - Lack of quality green areas and public spaces: lack of a guarantee for these areas and spaces - Priority of vehicular traffic over foot traffic - Problems with air pollution and high levels of noise - Difficulties derived from the production and management of waste

ACTIVITIES UNDERTAKEN The City of Madrid has undertaken different action in various areas in order to improve and reduce the main problems that are usually found. Likewise, it has begun activities that are more aimed at preventing future deterioration and, above all, it has included citizens in the different decision-making processes, promoting co-responsibility by all for maintaining a healthy environment. In terms of the activities begun, we would like to point out: - The development of a regulation directly related with the preservation of the spaces and a sustainable use of these spaces. - Start-up of different plans and strategies for action. Worthy of mention: a) Plan for managing the demand for water b) Local strategy for air quality c) Plan for a sustainable use of energy and the prevention of the climate change d) Guidance plan for bicycle movement in the City of Madrid e) Road safety plan f) Special plans for urban revitalisation (Recoletos-Prado and Manzanares axis). - With regards to the production and management of waste: a) Pick up of belongings. b) Clean points - Monitoring of acoustic pollution - Holistic plan for air quality: monitoring system and prediction system - Cycling green ring

126

- Strategic housing action for social integration - Initiatives for urban revitalisation: APR - Parking programme for bikes, motorcycles and scooters - Development of good practices manuals aimed at the population and at the institution itself. - Drafting of environmental studies - Development of the Agenda 21 - Activities of participatory and educational character for citizens

MAIN CHALLENGES AND PRIORITIES - To develop tools for creating a health urban environment - To give priority to accessibility when designing spaces - To increase the level of coverage by services and resources by planning a sensible use of them - To strengthen sustainable mobility - To promote improvement in housing living conditions, eliminating the problem of sub- quality housing - To strengthen an effective and balanced management of waste

“HEALTHY COMUNITY”: Embajadores Neighbourhood

Among the main problems in the Embajadores neighbourhood – which belongs to the Centre District – worthy of mention are: - A markedly aged population with a high level of dependency - Severe risk of social isolation

127

- Intense concentration, on the one hand, of an immigrant population and, on the other, of a native population with precarious economic resources - Significant existence of sub-standard housing and overcrowding. - Lack of green spaces - "Unhealthy" occupation of public spaces - Increase in social conflictivity and a subjective feeling of insecurity - Difficulties with the management of urban waste

Over the past several years, there have been different activities aimed at rehabilitation of the area that have been implemented, culminating in the declaration of this area as an Area of Holistic Rehabilitation. Among the measures developed, worthy of mention are: - Increase in police presence in the area - Declaration of the area as a residential priority area, restricting access by vehicular traffic - Increase in the provision of social action resources - Reinforcement of cleaning services, street cleaning and the pickup of packaging resulting from the high number of wholesale business located in this area - Establishment of areas and timetables for loading and unloading - Health inspections of business premises - Support for creating associations

However, despite the actions carried out, the area continues to be sunk in a process of severe deterioration, which makes it necessary to take another look at the work carried out to date and initiate new ways of intervening that will strengthen and increase the quality of life of its residents and the visitors staying in the area. Among the challenges: - To develop coordinated work among the different departments of the Madrid City Government - The improvement of the urban landscape, redrawing spaces and recovering them for pedestrians, improving accessibility and eliminating architectural barriers - Renovation of infrastructures, with special attention paid to paving, lighting of public spaces, gardens, street furniture and signage, updating supply networks... - To gain quality private spaces - To act on the problems of sub-standard housing - To encourage work with associations - To promote means directed at social integration and the encouragement of peaceful coexistence.

Theme 4: Use of Structural Funds in designing actions to develop "health gains"

FUND INITIAL FINAL DENOMINATION DECISION HELP AMOUNT DECISION FEDER 2001 UNDERW Improve environment and green 3,005,359.53 AY spaces (e.g. Vallecas Villas) euros FEDER 2001 UNDERW Environmental adaptation and 2,006,602.52 AY improvement, e.g., Julián euros Camarillo (San Blas) WASTE 2004 31/12/2008 Increase facilities for assessing 43,721,438.00 34,977,150.40 MANAGEM solid urban waste in the euros euros ENT Vademingómez Park COHESION FUND 2002

128

WASTE 76,785,683.00 61,428,546.40 MANAGEM euros euros ENT COHESION FUND 2002 WASTE Technical assistance for drafting MANAGEM project for recycled water ENT distribution network from COHESION ERAR Valdebebas-Rejas and FUND 2002 Viveros de la Villa, Madrid WASTE Carry out project for adapting MANAGEM the "Las Dehesas" waste ENT treatment center to the COHESION classification and recovery of the FUND 2002 subproducts resulting from selective pickup WASTE Installatin of degassing and use 73,547,683.00 58,838,146.40 MANAGEM of biogas, sealing and landscaped euros euros ENT recovery of the Valdemingómez COHESION tip FUND 2002 WASTE Technical assistance for drafting MANAGEM a programme to raise awareness ENT among citizens about preventing, COHESION minimising , reusing and FUND 2002 assessing municipal waste SEWAGE 35,472,793.00 28,378,234.40 MANAGEM euros euros ENT COHESION FUND 2002 SEWAGE 2000 2008 Technical assistance for drafting 445,076.00 MANAGEM project for recycled water euros ENT distribution network from COHESION ERAR Valdebebas-Rejas and FUND 2002 Viveros de la Villa, Madrid SEWAGE 2000 2008 Project for using recycled water 6.197,577.00 MANAGEM at the la China ERAR for euros ENT watering Madrd's parks COHESION FUND 2002 SEWAGE 2001/200 2008 Adapt the general spillway on 2,739,125.00 MANAGEM 4 the left side of the Manzanares euros ENT River COHESION FUND 2002 SEWAGE 2001 2008 Monitoring of Unitary Systems 21,128,845.00 16,903,076.00 MANAGEM Discharges on the left side of the euros euros ENT Manzanres River COHESION FUND 2002 SEWAGE 2001 2008 Monitoring of Unitary Systems 6,743,067,00 5,394,.453.60 MANAGEM Discharges on the right side of euros euros ENT the Manzanres River COHESION FUND 2002 SEWAGE 2001 2008 Reuse of the waste water from 2,444,873.00 MANAGEM the la China ERAR in Madrid euros ENT for 2nd phase of green zones COHESION (CONTROL ARCA 26/10/07)

129

FUND 2002 SEWAGE Modif. 2009 Installation of reuse of water 25,851,924.00 20,681,539.20 MANAGEM 2007 regenerators for water public euros euros ENT parks in Madrid North-East- COHESION Rejas network (included in the FUND 2002 decision are 4 other projects from the Alcobendas, Coslada and Guadalajara councils)

FUND INITIAL FINAL DENOMINATION DECISION HELP AMOUNT DECISION FSE 2005 2007 Southern Madrid Project 1.408.478.61 FSE 2005 2007 Madrid, companies and 1.089.790.00 conciliation FSE- 2004 Madrid, a city for conciliation 1.412.844.25 EQUAL FSE 2004 2005 BEGIN: accompanying women 405,000.00 in their process of professional insertion and business creation COHESION 2000 2006 ECOVALLE: Water spirals 1,033,600.00 FUNDS 2000/2006 FEDER 2006 2008 INTERREG IIC- 48,000.00 PROGRESDEC-SURPRISE Sustainability on urban renewal programs in southern Europe PROGRAM 2006 I3CON 126,186.66 ME R+D, VI FRAMEWO RK PROGRAM ME (2002- 2006) PROGRAM 2004 LA ROSILLA (CONCERT) 18,000.00 ME R+D, VI FRAMEWO RK PROGRAM ME 2005 MANUBUILD 258,706.05 2002 MEDITERRANEAN 421,810.69 VERANDAHWAYS (1ST PHASE) LIFE PROGRAM 2001 SUNRISE 74,160.82 ME R+D, VI PROGRAM ME COHESION 2001 GAVIA PARK (WATER 1,033,600.00 FUNDS SPIRALS) COHESION 2001 PROJECT FOR 9,860,834.45 FUNDS ENVIRONMENTAL IMPROVES IN LAVAPIES ARP COHESION 2001 URBAN PROJECT 3,744,452.00 FUNDS

130

R+D 2001 REGENT LINK 206,262.00 PROGRAM M, VI

After reviewing the proyects that Madrid City Council has carried on, with support of European funds, we can see that the aim priority of the city has been introducing coherence in the local and European strategy, so that, each proyect answers as directly as possible to the European guidelines. Studies data from the City of Madrid, warned that weaknesses can be grouped around two main axes: The first one is the inadequate treatment capacity of municipal waste and problems with water supply. The second one is the imbalance in the geographical distribution of the population, standing out on one hand the regressive demography and raised aging of the population, and on the other hand an insufficient awareness of equal opportunities.

Faced with this situation, Madrid has launched a series of initiatives, supported by European funds, designed to relieve and prevent these difficulties, integrating in its projects the aims of sustainable urban development and environmental protection and equal opportunities: according to that, the developed projects are divided mainly among those oriented to the investment in infrastructure related to water management and those related to improve social cohesion and exclusion prevention. Both lines of work are closely linked with the health and quality of life of the city, which seeks to develop them, to create a healthy environment, promoting and enhancing the "health city", through the development of balanced geographical structures and promoting the provision of quality basic services (water, air ,...), conducive to efficient and balanced waste management.

Sources - Directorate-General of Statistics Municipal Inhabitant Register Spanish Department of Treasury and Public Administration Madrid City Government - Directorate-General of Statistics 2005 Annual statistical report. Spanish Department of Treasury and Public Administration Madrid City Government - Institute of Statistics, Community of Madrid Statistics of the natural movement of the population Madrid City Government - Health survey of the City of Madrid Madrid Health. Institute of public health. Department of Safety and Community Services Madrid City Government 2005 - Health Study of the City of Madrid Madrid Health. Institute of public health. Department of Safety and Community Services Madrid City Government 2006 - White paper on Health Care Madrid City Government - Report from the Department of Employment and Citizen Services 2006 (currently the Government Department for Family and Social Services) - Action Plan for Lavapies. City Centre Office Government Department on Employment and Citizen Participation Madrid City Government, 2005

131

Torino - Italy

Maria Carmela Ricciardi Turin City Council - Urban Regeneration and Development Sector 26 th of July 2008

General socio-economic context: current situation and main issues related to health

Torino is the capital city of the Piedmont Region and it is Italy’s fourth biggest city. It has been, until the economic crisis of the Eighties, the industrial capital of the country and it is now transforming its economy towards a more high-tech and knowledge based one. Car industry, in particular the production of car components, is still an important sector in the local economy. Other important industrial sectors in the city include industrial automation, aeronautical parts, information technology and satellite systems. The food and drink industry is also a large employer together with textiles, banking and insurance and the publishing sector. Torino is home to a large number of research and development activities with the highest proportion of private spending on R&D in Italy.

Population Torino has 910.941 inhabitants (June 2008), with a slight increase of population after two decades of demographic decline (in 2001 it had 899.806 inhabitants, and in 1991 979.839). The female population is of 474.589 units (52.1%) and the male one is of 436.352 (47.9%). The increase of the population that Torino is experiencing is mainly due to migration flows and, in a smaller amount, to the natural birth rate (which is slightly higher than in the rest of the country) (L. Conforti and A. Mela, 2008). Torino seems attractive both to skilled and highly qualified professionals and to other workforce without any specific skill. It is possible to witness, in fact, the co-presence in the city of wealthy inhabitants and of the poorest part of the population, while the middle class is still moving towards the surrounding municipalities of the metropolitan area (and this is also due to the rising prices in the house market). In the city centre there is an higher percentage of professionals and medium-high income inhabitants, while less qualified workers and low income inhabitants are more concentrated in the peripheral neighbourhoods (in District 5 and District 6 , above all, that is to say in the Norther part of the city; see fig. 2).

Tab. 1 – Population per age (June 2008) Age M F Total % 0 – 14 53.492 50.555 104.047 11,42 15 – 24 38.088 35.906 73.994 8,12 25 – 29 25.212 24.812 50.024 5,49 30 – 49 145.174 141.543 286.717 31,47 50 – 64 83.817 91.053 174.870 19,20 65 – 74 50.757 61.821 112.578 12,36 75 – + 39.812 68.899 108.711 11,93 Overall total 436.352 474.589 910.941 From: Elaboration on the Statistics Unit Data - 2008

132

Fig. 1 – Structure of the population per age and sex (2008)

1000000

900000

800000

700000

600000 M 500000 F Overall total 400000

300000

200000

100000

0 0 - 14 15 - 24 25 - 29 30 - 49 50 - 64 65 - 74 75 - + Overall total

From: Elaboration on the Statistics Unit Data - 2008

The demographic data shows a certain fragility in the population structure visible in every city districts due to a majority of grown-up population (from 30-49 to 50-64 y.o.) and elderly (from 65-74 to over 75 y.o.), in comparison with the younger part of the population (from 0-14 to 15-24 y.o.). If we consider the growth of the ageing index 11 as well as the dependency index 12 over the last six years (tab. 2), it is clear that there is an ongoing progressive ageing of the resident population (also noticed at the regional and national levels) as well as a critical situation in terms of the imbalance of the structure of the resident population , with a strong dependency from the active population due to general ageing.

Tab. 2 – Ageing and dependency indexes Turin Municipality 2008 (June) 2002 (December) Ageing index 212,7 188 Dependency index 55,55 47 From: Statistics Unit web site: http://www.comune.torino.it/statistica/dati/demog/indicat.htm

The percentage of foreign population compared to the total population of the city is of 12,1% (June 2008).

Tab. 3 – Foreign population Turin Municipality Area N. of foreigners Overall Population Foreigners/Residents (%) Turin Municipality 110.353 910.941 12,1 From:Elaboration on the Statistics Unit Datas - 2008

11 The ageing index represents a dynamic indicator that assesses the ageing level in the population: values higher than 100 show a major presence of elderly in comparison with youngsters and children. 12 The dependency index is an indicator of economic and social relevance which highlights the number of inactive subjects every 100 units of active population (15-64 years old).

133

In 2006, the Report of the “Interinstitutional Observatory on Foreigners of the Province of Torino” classified, within the city area, District 7 and District 6 at the first and second rank, respectively, in terms of foreign residents, while identifying the 5 city areas with the highest presence of foreign population: Borgo Dora (27,3%), Aurora (24,1%), Monterosa (23,5%), Villaretto (22,8%), San Salvario (22,3%).

Fig. 2 – The districts in the Municipality of Torino

It is interesting to see that 4 out of these 5 zones are in the Northern part of the City: this polarisation in the territorial distribution of foreigners highlights the stronger attractiveness that these areas have with respect to the city centre and the Southern part of the city. These areas have been, in fact, interested by economic and social regeneration processes and offer, as a consequence, a more dynamic property market. For this reason, some parts of the central area provide a first and poor place to settle to migrants (especially those without any legal document), which is abandoned for better places as soon as the migrants increase and stabilise their income. As far as the age structure of the foreign population , the most represented age groups are the 30-49 y.o. and the 0-14 y.o. There is also a good presence of young people (15-24 and 25-29 y.o.) while the over 50 are under-represented and the over 60 nearly non-existent. The most represented countries in term of population are: Rumania, Morocco, Albania, China and Peru. 21% of the foreign population is self-employed (12% for the Italians) and also the level of education shows some differences: only 8,2% has the lower degree of education, compared with the 23,2% of the Italians. There is also a high rate of migrants with high school and university degree.

Employment In 2004 the unemployed population in Torino were of about 12.000 people. The majority of them were women (55,1%). Concerning the age, young people below 24 y.o. were represented 15,8% of the total amount, those between 25 and 29 y.o. the 17%, while the most consistent part had an age between 30 and 49 y.o. (52%), while the over 50 y.o. were the 15% of the total. Adult jobseekers with strong social difficulties are then the most represented, together with the foreign population (22%) (especially in comparison with the wider territory of the Province of Torino, where the foreign population sums up to 12% of the unemployed). The combination of

134

the two above mentioned characteristics shows that the unemployment in Torino is more fragile in terms of educational profile, which is lower for adults and not legally recognised and valorised for foreigners. But also graduates are slightly more present in Torino’s unemployed rate: they are 7,4% of the total amount, compared with a national figure of 5,5%.

Tab. 4 – Unemployment rate (2004) Turin Municipality M 6,86 F 9,81 Overall estimated value * 8,14

*The City unemployment rate has been estimated comparing the official rate in the Province of Torino and the data of the jobseekers in the Province and in the Municipality. Source: SRF, 2004

In 2005 the City had 434.000 employed people. The industrial sector had 96.000 employees (half of them in the automotive sector). Service sector employs 336.000 units (81.000 of whom in business services, 66.000 in health and education services and 58.000 in commerce). The bigger sectors of female employment are health and education (nearly 50.000 units), business (40.000), household care (28.000) and commerce (24.000). The high concentration of male employment (42.000) is in industry (36.000), commerce (34.000) and buildings (21.000). In 2004 new job opportunities available in the city were more than 100.000. Among them: 12,2% as temporary jobs; 60,7% as short term contracts; 27,1% as permanent jobs. One opportunity out of 5 is created by the industrial sector (20,9%), while 4 out of 5 by services (78,6%). Job offers are addressed for 1/3 to qualified personnel and for 2/3 to unskilled personnel (2004), showing that the city can actually provide good working opportunities to unskilled workforce, even if in a rather smaller amount that in the past.

Health and quality of life Health depends on several variables: genetic inheritance, lifestyle, exposition to risk factors such as addictions, working place safety, ageing, etc. The role of the population socio-economic characteristics as important health determinants, tough, should be stressed: social status, differences on education, culture, job and income, exclusion and lack of social relations are thus other factors which influence people’s life and health conditions. Besides the more traditional elements that refers to health promotion (regarding the welfare and prevention systems), some emergencies are coming out in recent years that needs specific attention. Among these: • the progressive ageing of the population . In percentage, Piedmont is the Italian “oldest” Region and anticipations elaborated by the National Institute of Statistics (ISTAT) highlight that within 50 years the over 65 y.o. age group will represent more than 40% of the total population; • an increasing social vulnerability , which is the exposition to the risk of poverty which affects a growing part of population and is mainly caused by the crisis of the welfare system, by the constant increase of the cost of life (which does not correspond to an adequate salary growth), and by the excessive flexibility – in terms of short-term contract – of the labour market which increase the young people dependence on their parents families and concerns an increasing number of adult unemployed workers with fewer chances to find a new job and, therefore, obliged to modify their lifestyles; • the growth of migration flows , which requires cohesion and social inclusion policies to promote integration and equal access to public services, health services in the first place (it

135

must be stressed, however, that the Italian law grants the right to health care to every person that lives – even if temporarily and without legal documents – in Italy).

In Italy the right to health for all citizens (ruled by the art. 32 of the Italian Constitution) is assured by the National Health Service (SSN). The SSN guarantees all its activities through the regional health services (Local Health Agencies, i.e. ASL, and public hospitals), by national bodies and institutions and by the State , whose main aim is to assure health assistance and safeguard as an individual fundamental right and a collective interest, to respect each person’s dignity and freedom. The SSN is a public system, it has a universalistic character and it is funded by the general taxation system and by the direct incomes drawn by the Local Health Agencies (health tickets, that is a partial contribution to overall costs of a medical service and full payment for other services). The SSN is characterised by a health programme system articulated in a National and many regional Health Plans.

The Piedmont Regional social and health plan 2007–2010 defines the political, organisational and administrative lines for health protection and promotion in the region. It outlines, in general terms, the medium-long term evolution of the health system starting from the analysis of the determinants of social and health claims and needs related to gender, age and different degrees of biological and social fragilities. Its main principles are: − the centrality of health , which has to be assured by the welfare system, but also by practising and enhancing disease prevention; − prevention , by removing or tackling factors that can negatively affect health (i.e. general socio-economic factors, gender and age inequalities, environmental and biological factors); − the centrality of women and men , which has to be achieved also through the inclusion of newcomers in order to preserve their rights, facilitate their access to services and respect their lifestyles; − a clear and responsible involvement of local institutions in planning and programming health care and promotion actions. Evaluation of the quality of services and of the effectiveness in responding to the population needs is another priority; − information ; − functional, intersectoral and inter-institutional integration within and among all health care sub-systems, particularly on the issue of prevention, support and rehabilitation of those persons who are in socio-economic difficulties or in fragile and vulnerable conditions; − a transparent and rational management of health which pursues equality, respects subsidiarity and promotes co-operation and solidarity within a framework of sobriety and austerity; − promotion of a responsibility ethics and willingness of health professionals to tackle issues on the basis of social and gender diversities.

The health network All citizens refer to the health services through the general practitioner (family doctor), the emergency unit, the medical practitioner, the hospital, the semi-residential, residential or home assistance. Prevention, diagnosis, care and rehabilitation interventions are delivered by local health agencies or public hospitals, private hospitals and nursing homes, research and scientific care institutes (IRCCS), and private laboratories. Public hospitals and University-college hospitals assure, among the others, hospital care, day hospital and day surgery services and medical practitioners examinations. The Local Health Agencies (ASL) deliver their health care services in district structures and in hospitals. ASL are organised in health districts which assure the basic health assistance and social-sanitary services, general and paediatric medical assistance, nursing support, home care,

136

extra-hospital assistance, residential and semi-residential care for elderly and disabled people; other services and activities. Some ASL services and departments in Torino and Piedmont are, for instance: − the Mental Health Departments (DSM): delivering psychiatric assistance; − the Addictions Services (Ser.T): devoted to tackling addictions to illegal and legal substances (alcohol, drugs, etc.); − the Piedmont network of Mother and Child Departments : delivering medical services to families, women, children and adolescents such as prevention, diagnosis, care and rehabilitation; − the Family Advisory Bureau: delivering assistance and support to families. It is a reference point for tackling issues such as preventions, sexuality, pregnancy, women’s health and children protection; − the Paediatric Advisory Bureau: delivering services devoted to protect children’s health by the means of individual and collective prevention initiatives, in collaboration with the SSN paediatricians; − the Health Information Centres for Migrants (ISI): experimental institutes created in 1996 by the Regional Council beside the ASL, in order to better organise health services for the temporary present foreigners. As far as the right to health for temporary resident foreigners in concerned, the Regional Authority for Health and Welfare edited in 2008 a Guidebook for Health Services for Migrants , addressed to all public and private professionals working in the Torino metropolitan area who deliver health and care services to those migrants which are not registered in the SSN. Another initiative in this field regards the Protocol of Intent signed by the Municipality, the ASLs and by one of the City Public Hospital to improve the social and health services addressed to foreigners.

Health related initiatives The topic of health and quality of life promotion engages all local bodies – first of all the Municipality as it is the “closer” institution to citizens. One of the city priority is the development of a functional, intersectoral and interinstitutional integration aiming at better using resources and shaping sectoral policies (e.g. regarding education, labour market, welfare, urban planning, environment, culture, sport and leisure time) towards health in a co-ordinate way. Since 2004 Torino participates in the Healthy Cities Project, promoted at the international level by the World Health Organisation and whose guidelines, methodology and objectives has been adopted, giving priority to health and well being of the local community in an interdisciplinary and intersectoral approach.

The following experiences , which are directly linked or follow the start of the Healthy Cities project, aim at creating useful instruments for programming policies in the city: − the Epidemiological Observatory on Women’s Health (2003), in collaboration with the Regional Service of Epidemiology; − the Socio-cultural Observatory on elderly people (2005) , is linked with the Healthy Cities sub-network “Healthy ageing” (phase IV); − the Observatory on Young People World (1987), its aim to influence the definition of policies for young people ; − the Observatory on Health (2006), set up by the Municipality in collaboration with the Regional Service of Epidemiology. Its main role is to influence the definition of related policies by working with other thematic observatories. The work of the Observatory is also related to the existing processes of local participative planning, to which it provides scientific and technical resources on health and socio-economic systems determinants.

137

− the City of Health Centre . Involving different municipal departments, the city districts, the ASLs, the CIPES Piemonte (Italian Confederation for Health Promotion and Health Education), IUHPE (International Union for Health Promotion and Education), the University, private bodies, co-operatives and voluntary associations. The Centre hosts the Healthy Cities Municipal Office and the European Centre HIUPE-CIPES.

The Municipal Social City Plan which is also an objective of the “Torino Metropolitan Area Second Strategic Plan”. Its main objective is to connect in a synergic way local interventions aiming at producing positive effects on: citizens’ social well-being and quality of life, knowledge and promotion of the territory, equal opportunities and social cohesion. It is articulated into 6 Technical Boards: elderly, disabled, youngsters, children, integration of migrants, professional training and adults employment.

The Torino Social Services Plan 2003-2006 is one of the first Italian examples of participated planning in this field. It is the result of all local political, institutional and social actors involvement (more than one thousand people and two hundred organisations) which results in a widely shared project with well defined actions and objectives. The Plan concerns the following policies: for foreigners and Roma people; for adults, families, children, disabled people and elderly; for home care.

Theme 1: Health Impact Assessment (HIA) and the use of urban health indicators

Torino has no experience in using HIA . Indicators on “urban health”, but more generally on “quality of life” have been used in the context analysis developed for designing tools, policies and public calls launched by the regional, provincial and municipal bodies. These indicators are not, though, part of a system of monitoring and assessment that explicitly refers to quality of life. At the regional level, in the socio-sanitary programme (e.g. in the “Regional Social Health Plan 2007 – 2010” or in the “Health Atlas in Piedmont”) the following indicators can be identified: - social and demographic context: number and composition of the population, age groups, households, features of the migrant population, employed/unemployed, level of education, etc.; - health conditions: working conditions, lifestyles, drug, game and alcohol addictions, diseases incidence, vulnerable groups, strength and weakness of the health system, territorial distribution of health determinants, etc.

At the city level the experience of the “City Social Plan” should be highlighted. The Plan aims at monitoring those dynamics that link social wellbeing with competitivity, taking into account that there is a relation among social inequality, wellbeing and interventions to regenerate specific part of the city. The main chapters of the Plan are dedicated to: training, job and growth; ageing population; younger population; inclusion and accessibility for disabled; integration for migrants. Policies that addresses these issues refer to different department of the Municipality and the Plan should help to co-decide and co-operate, with public and private actors, in the definition of new measures and actions to tackle, especially through transversal strategic axes, several problems. The Plan foresee, besides, city district boards to follow more closely the development dynamics of the different part of the city. These boards will mainly work to define an Health and Wellbeing Profile and to monitor the activities developed at district level.

138

The evaluation of the impact on citizens’ health (in its wider sense of quality of life) of all policies and interventions, not only the sanitary and welfare ones, is an open debate among all private and public actors working in the city, the province and the region. The “Regional Socio-Sanitary Plan 2007-2010” clearly shows this approach as it underlines the importance of «protecting and promoting health» as a task for all policies. The Regional Authority for Health Protection supports and promotes public authorities’ assumption of responsibility with the purpose of driving local administrators to include the impact that every policy has on health in their decisions, in order to concretely contribute in the improvement of general life conditions. The objective is that Local Authorities implement actions to protect and promote health within the framework of their plans and programmes, starting from the evaluation of the quality of services and of their effectiveness in supplying the collective need for health. This topic will be treated during the 8th IUHPE 13 European Conference on Health Promotion and Education, “ New frontiers: future political, cultural and scientific challenges for Health Promotion”, which will be held in Torino from the 9 th to the 13 th of September 2008. This conference will be an occasion for deepening and comparing different competencies (public administrators, political representatives, researchers, professionals – not only on health - working in different public, private and voluntary sectors) on the basis of a partnership approach. CIPES Piemonte (Italian Confederation for Health Promotion and Health Education) activities are part of this strategy. CIPES is a member and founder of the IUPHE, a body that in more than fifty years of life has supported worldwide strategies and projects on health promotion in collaboration with WHO, Unesco and Unicef. CIPES Piemonte is composed by individual, collective, public, private and institutional members (such as the Region, Provinces, Municipalities and Districts). Its core activity is the management of the network of members and the facilitation of their exchanges in order to disseminate information and to compare experiences in every theoretical and practical field dealing with health promotion and health education.

Theme 2: Policies and actions for an active and healthy ageing

The ongoing ageing of the population is a national phenomenon which is even more visible at regional level (being Piedmont the Italian “oldest” region, in percentage) and at the local one. An extensive research on the condition of elderly in the Region shows how the concurrence of diverse factors (low or insufficient income, family and environmental conditions determining isolation, psycho-physical conditions precluding an autonomous life), obliges nearly 8% of the over 65 y.o. to live in more or less serious conditions of dependency. On the contrary, 92% of them is still able to live an autonomous life, keeping a good level of health, even from a psychological point of view, which gives them the opportunity of carrying on many activities including a further value compared to younger people: free time. The Piedmont Region promotes several initiatives aiming at supporting elderly’s participation in social life: jobs, cultural and recreational activities which foster people’s development and growth and contribute to prevent psycho-physical decay and, in the same time, allow to preserve seniors’ experiences and skills. For the partially or totally non-self-sufficient elderly persons, the offer of services is mainly structured to keep the person in his/her own home, avoiding hospitalization and improving the qualitative level of the welfare services delivered in structures.

The Municipality of Torino promotes numerous initiatives for supporting active and healthy ageing. For instance:

13 International Union for Health Promotion an Education.

139

• A.A.A. – Agenzia Anziani Attivi (Active Ageing Agency). A project involving many Company Pensioner Associations and the Municipality. Its purpose is to match the pensioners’ demand for voluntary activities and the “offer” of the related organisations; • Pass60 . A yearly card which offers the possibility of participating in cultural, sport and leisure initiatives devoted to over 60; • the Silver Games , which are now at their tenth edition. Created in 1997, in collaboration with SUISM (Interfaculty University of Motorial Sciences) they give over 60 the opportunity to practice sport and have now become a city event; • A Silver Year , promoting different activities such as the “Silver Menus”, the “Silver Games”, “New Year Party” and the “Silver Fan”; • Civic Grandfather , voluntary activities carried out by seniors; • the Self-help Service : a municipal strong reaction to criminality, which unfortunately hits elderly very frequently. It is a free service which helps elderly people victims of violence by offering them concrete supports delivered by highly qualified associations and by the Municipal Social Services.

In the whole city a network aiming at keeping elderly people in their own environment is active. The network offers a set of interventions which vary from ready-made meals, laundry service or tele-aid to the daily and/or nightly hospitality. Temporary hospitalizations are sometimes accepted in order to ease and support families, and, for those who can no longer live in their own homes, permanent hospitalizations are provided. Projects addressed to elderly people in difficulty are activated by districts social services and by the ASL Geriatric Evaluation Unit (GEU) Commissions. These commissions are made of a multidisciplinary team composed by ASL health professionals and by municipal social workers. Social Services and GEU Commissions grant the request for intervention and elaborate a socio-sanitary project which seeks, when possible, to keep the patient at home. The Service also informs the senior and his/her family on the procedures to get the needed services. To the purpose a Guide of the Facilities for Elderly People has been produced, to provide updated information on the resources for the population. The city has 31 dedicated structures for the elderly and the province 61, while 40 are spread in the rest of the Region (taking into account that in the Torino metropolitan area and province the majority of the population of the Region is concentrated).

Priority, needs, challenges

Income : many elderly have low incomes and live in poverty or at risk of if also because of the increasing cost of life. Isolation : many elderly persons live alone and often cannot lean on any family or neighbourhood networks, so it is difficult to contact them and find proper solutions to their problems. Health system accessibility : the available amount of information on the health system structures and facilities does not always reach in a clear and user-friendly way the target population. Disabled elderly persons : there is a growing number of disabled elderly people that exceeds the availability of places and services in the existing structures and facilities.

Theme 3: Healthy Places and Healthy Environment

The ongoing processes of regeneration in some city areas, especially in previous industrial sites and brownfields (as, for instance, in and around the “Backbones” areas), has physically changed the face of the city. These development processes are to transform these areas (which,

140

considering only the industrial sites consists of more than 2 millions of square meters) in new residential areas, university campuses, commercial and services areas in which attention is paid (not always with good results) to the quality of the built environment and public spaces. These processes does not always result in positive transformations, mainly because the different timing of the interventions allows for the creation of marginality enclaves in which the lack of security and the rate of micro-criminality increase. In these cases, e.g. in the so-called “Toxic Park” on the Stura river banks, the Municipality is trying to fight exclusion and criminality with culture (summer festival and a temporary concert hall), while the development project is searching for funds. Another important development process regards the closing waste deposit area of the city, Basse di Stura, a 540 he area on the Northern borders of the Municipality that will be regenerated and transformed in a green area with public facilities and a waste-to-energy plant. Some other city areas are still characterised by high level of unemployment, social marginalisation, residents’ lack of identity and sense of belonging, lack or insufficient aggregative spaces and green areas, lack of social and cultural services, concentration of social housing blocks in bad conditions, with a socially excluded population. In this cases a certain economic and productive vitality can be fostered, while the presence of historical, cultural and above all environmental potentialities need to be valorised.

For over ten years the City is taking forward urban regeneration interventions, part of a broader development policy. These initiatives, such as the Special Project for Neighbourhoods, the Urban Pilot Project (UPP) “The Gate – Living and not leaving”, the CI Urban II “Mirafiori Nord” are part of the city development and growth plan and they have been implemented alongside experiences like the “Torino Internazionale Strategic Plan for the City”. This development policy was influenced by the participation of Torino in the European and national debate on the themes of regeneration and promotion of urban development related to policies and more effective instruments for achieving these objectives. This political approach have been also developed thanks to the active participation of the City in European networks such as Eurocities and Quartiers en Crise . What the municipal Urban Regeneration and Development Sector experienced, and continues to do in targeted areas, is a global strategy and an innovative methodology. Its aim is to address the issue of urban regeneration adopting the integrated approach boosted by the European Union in the Urban I and II Community Initiative Programmes. The challenge is to renew parts of the city "attacking" urban deprivation from a physical, but also social, cultural and economic point of view. To this aim, since the Nineties the city has adopted and experimented several integrated programmes of urban regeneration, using ordinary and special funds. Among these experiences: - the Urban Renewal Programme (PRU), targeted for deprived neighbourhoods with high rate of public housing estates. The structure of this programme is inspired to the European Union URBAN Initiative, thus paying attention to the social and environmental part of the renewal process, other than the physical one. Furthermore, the PRU is always carried on together with a “Piano di Accompagnamento Sociale”, that is a specific plan addressing the issues of participation and community development. The city district that had a PRU are the no. 5, 6 and 10. - the Neighbourhood Contracts, first and second phase. Also dedicated to deprived areas with public housing estates. In this case the funds are to be used only for physical interventions on the buildings, while the Municipality, and other players if any, finances all the other actions that regards, for instance, regeneration of public spaces and cultural activities. These contracts regards the district 1 (for the first phase) and the districts 2, 5 and 6 (for the second phase). - the Parco Dora Committee, that refers to a vast area (more than 1 million square meters) in the Backbone no. 3. The Committee, created by the Municipality, districts 4 and 5,

141

and other public and private actors, is a multi-functional contact point for the area regeneration and provides a monitoring on the ongoing transformations.

The “Barriera di Milano” borough For over ten years the City of Turin has promoted and carried out many studies and researches aiming at measuring and examining the differences among different city areas in terms of demographic, occupational, socio-cultural and economic structure, with the purpose of adapting urban policies to the city needs. One of these studies made clear how the combination of critical elements were concentrated in a relative small number of areas, mainly located in the Northern part of the city (in the former working class boroughs) and in their big social housing blocks. These areas hugely experienced the economic crisis due to the transition from the Fordism economy to the post-Fordism phase (closure of big industrial plants, increase of unemployment and related social problems, etc.) (L. Conforti and A. Mela, 2000). A recent research has confirmed that in the Northern part of the city, and in particular, in the Barriera di Milano borough, social deprivation due to the combination of several problematic factors is still present (L. Conforti and A. Mela, 2008). Over the last years Barriera di Milano is, in fact, experiencing dramatic transformations in its social, economic and spatial structure, so that it can be described as «a place at the margins […] not so much from the city, but rather from the economic, cultural, social and, even, territorial development processes» (T. Ciampolini, ed., 2007, p. 56). Barriera di Milano is progressively and ineluctably loosing its identity as a city neighbourhood developed as a factory borough, but it is also an area that needs new tools for diagnosis and interventions in order to find a proper way of “steering” new and positive changes. Barriera di Milano is located in District 6 (Northern – Eastern part of the city) and it is historically divided into four boroughs: Montebianco, Monterosa, Maddalene and Cimitero Generale . It is still a popular and working class neighbourhood, which has been experiencing different migration flows. These waves started in the first decades of 1900 with farmers leaving the countryside, followed between 1955 e 1965 by Southern Italy workers attracted by the car industry development and finally, in the last decades, by migrants coming from all over the world. Till the Eighties, the area was a kind of enclave within the city structure as its inhabitants’ working and social life was mainly carried out within its borders. In those years the homogeneity of the working class contributed in defining strong identity and sense of belonging characterised by a solidarity that led to the development of many local associations. Then, the crisis of the industrial system and of the Fordist social organisation, the occupational and economic uncertainty, the arrival of new inhabitants with different cultures and religious beliefs as wells the occurrence of new urban poverties have produced a fragmentation of the social classes, a lack of identity and an overspread feeling of insecurity.

Population The population (2008) is of 50.338 inhabitants, nearly 50% of District 6 total population and 5,5% of Torino population. It is interesting to highlight that, in this area, ageing population is less a problem than in the rest of the city, since the population is younger than average.

Tab. 5 – Ageing index (June 2008) Barriera di Milano’s boroughs Ageing index No. Position Cimitero Generale 199,02 Medium high Maddalene 228,12 Very high Monterosa 137,96 Medium low Montebianco 114,27 Medium low

142

The Monterosa and Montebianco boroughs actually show a lower ageing index than the city average (212,7) as well as the District one (184,9), this because of a strong presence of younger migrants. These boroughs, on the basis of the 2008 Municipal Statistics Office data, show a larger presence of families with children in comparison with the total of Torino population: nearly 11%, versus a city average of 9,5% and a District one of 10%. Actually in these two areas the dependency index has less critical values than in the rest of the city. In June 2008 the relevance of the foreign population, compared with the total of the population, is clearly higher than in District 6 and in the whole city (see tab. 6, below). In line with the general positive trend of the foreigners’ presence at city and district level, these boroughs show an increase of 2-3 percentage points over the past three years.

Tab. 6 - Foreign residents (June the 30th 2008) Number of Total Foreigners/residents Foreigners/residents - Area Foreigners population - % (June 08) % (December '06) City of Torino 110353 910941 12,1 9,4 District 6 17539 106562 16,5 12,60 Barriera di Milano: Cimitero Generale 127 852 14,9 n.a. Maddalene 1267 13261 9,6 7,2 Monterosa 8049 26370 30,5 23,5 Montebianco 2703 9855 27,4 21 From: Elaboration on the Statistics Unit Data - year 2008

Concerning the countries of origin, in the whole Barriera di Milano Rumanians are the majority (33,7%), followed by Moroccans (24,5%) and Chinese (6,8%). The structure per age and sex of the resident foreign population has similar characteristics than the rest of the foreign population living in District 6.

The most represented age groups are those between 30-49 y.o. (47%), followed by the very young 0-14 (20%) and by a good presence of young people, 15-24 and 25-29 y.o. (respectively 12% and 11,5%). The over 50 y.o. are under-represented (7%), while the over 65 y.o. are nearly absent (below1%). The structure per sex is fairly homogeneous. Unlike the city central areas, the majority of foreigners living in Barriera di Milano choose to stay in a permanent way, often with their families, children attending to the neighbourhood schools, sometimes buying a flat. The population density of the area is very high: 15.194 inhab/sqkm (nearly three times more than the city one, even higher than in District 6) with a peak in the Monterosa borough (31.318,29 inhab/SqKm). The population increase is mainly due to the attraction the area wields towards migrants above all, as there is a certain availability of relatively low rent housing and property values are more accessible in comparison with the rest of the city. Generally speaking, in Barriera di Milano two housing typologies can be identified: the houses built in the beginning of 1900 (above all in Montebianco) and the blocks of flats built between 1950 and 1970 (in Monterosa). Buildings are mainly private owned: 63% of the population own its flat, 32% rents a house and 5% has houses cost-free. In the area there are few social housing blocks, while in neighbouring areas (in Regio Parco, for instance) the situation is completely different.

143

Fig. 3 – Structure of the population per age and sex, District 6

20000

18000

16000

14000

12000 M 10000 F Overall total 8000

6000

4000

2000

0 0 - 14 15 - 24 25 - 29 30 - 49 50 - 64 65 - 74 75 - + Overall total

From: Elaboration on the Statistics Unit Data - 2008

Employment

The District 6 is placed at the second place in the city (after District 7) for the number of jobs available, with a peak in Monterosa and in Regio Parco boroughs. More generally, in District 6, the number of unemployed per 1000 inhabitants in working age is 16.3%, the highest score in the City. A survey concerning employment in this area was carried out in 2004, following the creation of a Local Board for monitoring employment issues , a body composed by different public and private actors that at a district level, promotes actions in support of vulnerable groups in the labour market (S. Ronconi, ed., 2004). The large majority of jobseekers is represented by women, has a poor school curricola and is generally composed of un-skilled labour force (Torino Employment Centre – CPI, 2003). The City Job Information and Orientation Services deals especially with low qualified unemployed within an age group of 45-50 y.o. and more, since they often do short-term or occasional jobs, have poor competencies, and often social and family problems. The available instruments of the active job policy , on the other hand, do not clearly respond to the age issue and the lack of skills. As regards women, beside the emerging phenomenon of migrant women, they are the biggest group in the Job Orientation Services, especially those over 45 y.o, with low educational qualifications and income difficulties.

Economy The economic activity balance 2006-2007 is positive, in line with the city trend. The situation of the economic growth in Barriera di Milano (+3,5%) is even better than in comparison with the District 6 average (2,8 %) and to the whole city (1,7%). Higher values can be seen in some boroughs, particularly Cimitero (5,9%), Montebianco (+4,2%) and Monterosa (+ 4%).

144

Barriera di Milano is characterised by a typical industrial city economic structure, with a substantially stable trend. Its main characteristics are: - there is an high number of enterprises in the “Commerce” sector, (higher values in comparison with the city average), followed by the “Services” sector (lower values in comparison with the city average). Enterprises in the “Industry” sector have a higher presence in comparison with the city average, the economic crisis notwithstanding; - there is a relevant number of enterprises still working in the automotive sector, while there is a weak presence of ICT enterprises, even if their number is growing in the last years; - as regards other sectors than industry, there is an high incidence of handicraft enterprises and a predominance of “services to enterprise”.

Public services, facilities and spaces In Barriera di Milano there is lack of local public services and facilities (such as schools, green areas, meeting an aggregation spaces, car parks, sport facilities, etc.), also related to the arrival of households which will settle in the new housing development estates in the Spina 4 borough. There is also a lack of public social services , this causing insecurity and precariousness, especially among elderly people. As regards the ageing population , the lack of aggregation centres must be highlighted, since they do not only respond to the necessity to spend time in an active way, but also to meet other people and carry on common activities. As regards migrants , there is a need for services and places encouraging migrants’ integration in the social fabric; their growing number, besides, requires integration policies as foreigners are often seen as those who “withdraw” the resources from the territory without giving nothing back. The presence of migrants is often represented as a cause of discomfort and unsafety. As regards the use of public spaces , the presence of handicraftsmen who work in the courtyards represent, on one hand, a resource used also by people who do not live in the area, but, on the other hand, it is important to underline that this kind of activity may cause discomfort for the lack of proper spaces and adequate structures: actually they increase the level of the already existing noise pollution and contribute in the road system collapse, a phenomenon which constantly happens in some streets and in rush hours. [Sources: Osservatorio Lavoro – Divisione Lavoro (elaboration on CCIAA and EAAEP data, 2005, 2006, 2007 )].

Built environment The housing estates are generally in need of initiatives favouring their renewal, taking into account that the majority of the households (those of the migrants above all) cannot guarantee a proper maintenance of the buildings due to their low income. Abandoned buildings, irregular maintenance of the apartment blocks, low quality in lighting and the general lack of infrastructures, combined with the lack of green areas and services as well as unstable safety conditions in some parts of the borough, shape a context poor of attractive elements and with low urban values. The link between the environmental degradation and safety is clear, but the preservation of public spaces is one of the most difficult issue that the Local Authority has to deal with. Brownfields, with random squatting, constitute a serious problem. The area around the ex- INCET factory, for instance, is described as an unsafe one, especially in the evening and at night, because of the presence of drug-pushers and addicts. Furthermore, in the area emerges the contradiction between the need of green spaces and the fear that they can immediately become degraded, useless and unsafe places. The associative fabric and the participation of the citizens, that have been traditionally strong, risk to be weakened by the perception of the insufficient results of the last years development policies and by the City’s lack of attention to the neighbourhood claims. This trend could also

145

be reinforced by the uncertainty on the realisation of those project that local residents consider as a priority.

Ongoing transformations in the area At the borders of Barriera di Milano (and only partially within it) some important short and mid-term urban transformations are occurring, in particular the works concerning the so called City “Backbone” (i.e. the underground railway link that results in new available spaces on the surface). The Backbone has been divided in four trunks and the nearest to the Barriera di Milano is the “Spina 4”, in which the main actions regards the renewal and re-use of dismissed industrial sites for new housings, green areas and shopping ares. Other important transformations regard: the realisation of the Line 2 of the Underground ; the re-qualification of the Scalo Vanchiglia area (ex railways area) and its surroundings, through the realisation of an urban park, private housing estates, facilities for care services and for services to enterprises; the regeneration of the ex–INCET industrial area, with the realisation of a centre for different religious beliefs, warehouses for the City Cinema Museum, spaces for local associations, a police station, a kindergarten and infant school; the renewal of the Docks Dora buildings (also old industrial buidings) and its surroundings; the transformation of the ex-FIAT Officine Grandi Motori industrial area to host new housing estates, facilities for commerce, tertiary, handicraft and service activities.

Theme 4: Use of Structural Funds in designing actions to develop "health gains"

POR FESR (ERDF Regional Operational Programme) Managing Authority : Regional Department for “Productive Activities” Decision of approva l: C(2007) 3809 del 02/08/2007 Approved measures: Priority axis 1: Innovation and “productive transition”; Priority axis 2: Sustainability and energy efficiency; Priority axis 3: Territorial regeneration.

POR FSE (ESF Regional Operational Programme) Decision of approval : C(2007)5464 del 06/11/2007 Managing Authority : Regional Department for Education, Vocational Training and Job Approved measures: Priority axis I: Adaptability; Priority axis II: Employability; Priority axis III: Social inclusion; Priority axis IV: Human capital; Priority axis V: Transnationality and inter-regionality.

Only the 2000-2006 programming period is considered, as the current period 2007-2013 is just at the beginning of the implementation phase.

Docup 2000-2006 (ERDF-funded) Priority axis 3 – Local development and enhancement of the territory: measure 3.1 – integrated programmes. This measure funded about 20 integrated programmes, but it is to be underlined that interventions were mainly addressed to development issues.

Priority axis 4 – Social cohesion: measure 4.1 – social inclusion interventions. This measure was devoted to the rehabilitation of buildings, areas, open spaces (especially in deprived urban areas) to be dedicated to social and cultural use. About 50 projects had been

146

funded under this measure, in the eligible areas (in 2000-2006 not all the regional territory was eligible for ERDF – because of the so called “zoning”).

ESF : any specific actions funded under ESF regional operational programme can be directly connected to health and quality of life.

Only some examples are given, as the topics (especially quality of life, as it involves different policies and a number of different target groups with dedicated policies) are very broad and it is quite an heavy (i.e. mission impossible…) exercise to map all the different regional, national and European policies involved.

1. Regional programme “Wi-Pie” (a programme aimed at extend ICT infrastructures and their use to the whole Region) is funding some pilot actions of e-health (health care for aged people, improving the efficiency of health examinations); 2. the Agency for Metropolitan Mobility has been recently jointly created by the Region, the Province of Turin, the Municipality of Turin and other municipalities of the metropolitan area, in order to improve the efficiency and the coordination of the mobility system; 3. e-government: different initiatives to improve efficiency of public services for citizens; 4. regional programme funding different kind of child care services and structures; 5. regional and national funds to support families with more than 3 children (services for children, tax reductions, …) and for the domestic care of aged people.

Health issues aren’t directly addressed by Structural Funds, a good exception being the topic of e-health, improvement of health services by exploiting ICT potentialities, but, in the ERDF ROP, the measure devoted to innovative ICT services is mainly addressed to SMEs. This is due to the fact that Structural Funds for Competitiveness Regions (i.e. Objective 2 Regions) are mainly devoted to innovation and competitiveness (75% of resources are to be allocated to actions directly linked to Lisbon strategy). Quality of life has a strong cross-sectoral character: different policies (e.g. health, mobility, social policies for mothers, young and aged people, e-government, …) are involved, and an integrated approach and coordination of policies are required. This cause problems because of the traditional sectoral approach of public administration. In this context the ERDF ROP of Regione Piemonte will fund, under Priority axis 3 – Territorial regeneration, integrated plans whose aim is development and increased competitiveness of a specific area. Within these plans some actions to support and improve quality of life could be foreseen, if consistent with the general aim of the plan.

Sources Bibliography: AAVV, Non c’è Barriera senza Spina. Indagine sugli insediamenti abitativi di Spina 4 a Torino , Cooperativa Sociale Marca, Torino, 2008 T. Ciampolini (a cura di), Barriera Fragile , Ed. IDOS, collana Territorio, Roma, 2007 L. Conforti, A. Mela, La configurazione sociale dei diversi ambiti spaziali nella Città di Torino , IRES Piemonte, Torino, 2000 L. Conforti, A. Mela, La configurazione sociale nei diversi ambiti spaziali della Città di Torino e i processi di mobilità residenziale , IRES Piemonte, Torino, 2008 S. Ronconi (a cura di), Tavolo di osservazione sulle problematiche occupazionali della Sesta Circoscrizione: Rapporto di ricerca e sintesi del percorso di costituzione del Tavolo , Città di Torino – Assessorato Lavoro Formazione Sviluppo, 2004

Documents of analysis and planning – Projects and feasibility studies: PTI “Barriera mobile: infrastrutture e qualità della vita nel quadrante est- nord est di Torino”

147

PISL “Ricucitura di ambiti urbani storicamente separati – Aree ricomprese nelle Circoscrizioni 5, 6,7” Regione Piemonte: − Piano socio – sanitario regionale 2007 – 2010 − Lo stato di Salute della popolazione in Piemonte − Atlante sanitario del Piemonte − Guida ai Servizi Sanitari per Immigrati

Sites: Ministero della Salute http://www.ministerosalute.it/cittadini/cittadini.jsp

Regione Piemonte http://www.regione.piemonte.it/sanita/ http://www.regione.piemonte.it/sanita/program_sanita/ http://www.aress.piemonte.it/ (Agenzia Regionale per i Servizi Sanitari) http://www.regione.piemonte.it/polsoc/ (Piemonte Sociale) http://www.regione.piemonte.it/sanita/ep/atlante/riepilogo.htm (Atlante sanitario del Piemonte) http://www.piemonteimmigrazione.it/ (Osservatorio sull’immigrazione in Piemonte) http://www.regione.piemonte.it/polsoc/servizi/anziani.htm (Servizi per anziani)

IRES Piemonte http://www.ires.piemonte.it http://www.regiotrend.piemonte.it/

CIPES Piemonte http://www.cipespiemonte.it/ http://www.cipespiemonte.it/piani_reg_piem.php

Provincia di Torino http://www.provincia.torino.it/salute.htm http://www.provincia.torino.it/speciali/fragili_orizzonti07/fragili_orizzonti.htm

Comune di Torino http://www.comune.torino.it/relint/network/citta_sane.shtml http://www.comune.torino.it/gga/ (pagina Giovani Genitori Anziani) http://www.comune.torino.it/pss03-06/ (Piano dei servizi sociali 2003-2006) http://www.comune.torino.it/aaa/ (Agenzia Anziani Attivi)

148

III. Health and Quality of Life in EU Cities: A Synthesis

On the European stage the EU, and especially the European Commission through the DG SANCO, is active in health promotion and linking issues of the environment and health policies together.

On 23 October 2007 the European Commission adopted a new Health Strategy, “Together for Health: A Strategic Approach for the EU 2008-2013 ”. This Strategy aims to provide, for the first time, an overarching strategic framework spanning core issues in health as well as health in all policies and global health issues. The Strategy

14 Byrne D. (2004), Enabling good health for all. A reflection process for a new EU health strategy , EC – DG Health and Consumer Protection, Bruxelles.

149

aims to set clear objectives to guide future work on health at the European level, and to put in place an implementation mechanism to achieve those objectives, working in partnership with Member States. The Strategy focuses on four principles and three strategic themes for improving health in the EU. The principles include: - taking a value-driven approach; - recognising the links between health and economic prosperity; - integrating health in all policies; - strengthening the voice of the EU in global health.

The strategic themes include: - fostering good health in an ageing Europe; - protecting citizens from health threats; - dynamic health systems and new technologies.

The Health Programme is the key means to implement health objectives at European level. The “ Second Programme of Community Action in the Field of Health 2008- 2013 ” follows the first Programme of Community action in the field of public health (2003-2008) which financed over 300 projects and other actions. The Health Programme answers to the fact that many Community policies and actions have an impact on health and health systems across Europe. Yet, they are often developed within a different policy logic and decision makers are often not well aware of potential health effects. Important health determinants cannot be influenced by health policy on its own; there is a need for co-ordinated actions involving other policy areas such as environmental, social or economic policies . To this purpose, it is essential to take into account the Lisbon Agenda, being this the key EU policy on economic growth and productivity, and to mainstream health into the Lisbon Agenda is one of the most important achievements of mainstreaming health into other policies. The link between health and economic prosperity is more and more widely recognised, in particular in relation to the ageing population (the Healthy Life Years indicator, a measure of years lived in good health, being the only European Structural Indicators of the Lisbon Agenda that directly relates to health).

According to what has been said above, the attention can be focused on three issues of the Health Strategy – and their determinants – that can, in particular, been considered as important for an healthier Europe in which there are better quality of life conditions for all, taking into account the city/region level. These issues are: - lifestyle. Lifestyle related health determinants are multi-dimensional. These determinants are linked to number of major health problems. Also, some health issues share same determinants such as tobacco, alcohol, and nutrition. Health problems linked to lifestyle related health determinants can be life-situation specific (e.g. in childhood or in old age) but they can also be strongly linked to cultural aspects. In addition, socio-economic factors are an important reason for variations in health. Addressing these factors is considered as important in the framework of the EU Health Strategy, and a comprehensive health promotion in various settings (e.g. schools, workplaces, families and local communities) has proven to be efficient in addressing health determinants.;

150

- health inequalities and their socio-economic determinants. Health inequalities lower the ability of huge numbers of EU citizens to achieve their potential. Action to reduce health inequalities aims: to improve everyone’s level of health closer to that of the most advantaged; to ensure that the health needs of the most disadvantaged are fully addressed; to help the health of people in countries and regions with lower levels of health to improve faster; - the environment. The presence of natural or man-made hazards is a source of environmental diseases, which might be seen as the visible and clinical indication of inadequate environmental conditions. Key areas of action could be: outdoor and indoor air pollutants quality, noise, indoor environment and housing conditions, water quality contamination, electromagnetic fields and radiation, chemical exposures. The impact of these factors are felt in association with hearing problems, sleeping disorders, stress leading to hypertension and other circulatory diseases, skin and other cancers, asthma, or birth defects.

Good health is something which everyone wants – for themselves, their children and for the wider economic and social benefits it brings to our society. It plays a major role in long-term economic growth and sustainable development. This is especially true in urban areas, where the environmental, economic and social dimensions meet most strongly. Cities are where many environmental, economic and social problems are concentrated, but they are also the national economic drivers, the places where business is done and investments are made. Four out of five European citizens live in urban areas, and their quality of life, well-being and health is directly influenced by the state of the urban environment, economic and social factors . The attractiveness of European cities will enhance their potential for growth and job creation, and cities are therefore of key importance to the implementation of the Lisbon Agenda 15 .

Health as a resource

15 European Commission (2006), Cities and the Lisbon Agenda: Assessing the performance of cities , EC – DG Regional Policy, Bruxelles (http://www.eukn.org/binaries/eukn/eukn/research/2006/2/cities-and-the-lisbon- agenda.pdf; visited on the 15 th of October 2007).

151

They must work together towards a health care system which contributes to the pursuit of health. The role of the health sector must move increasingly in a health promotion direction, beyond its responsibility for providing clinical and curative services. Health services need to embrace an expanded mandate which is sensitive and respects cultural needs. This mandate should support the needs of individuals and communities for a healthier life, and open channels between the health sector and broader social, political, economic and physical environmental components.

The importance of the urban dimension

All these suggestions directly, or indirectly, refers to health and quality of life and, thus, need to be tackled. It is also clear, though, that these suggestions call for a greater effort than those that can be done by cities alone, thus stressing the importance of a coordinated action among the EU, the national, the regional and the local level in the field of health and health related policies. Conditions in cities, sometimes compounded by urban planning practices, can be in fact detrimental to health. Healthy

16 www.eu2007.de/en/News/download_docs/Mai/0524-AN/075Dokument Leipzig Charta.pdf

152

urban planning focuses on the positive impact that urban planning can have on human health, well-being and quality of life, and reflects WHO's broad definition of health. The health and well-being of any population requires a holistic approach that includes the involvement of many agencies and gives ownership to the communities involved. The traditional notion of top-down delivery of health care is no longer acceptable to central governments, who are seeking greater value for money, or – from another point of view – who are continuously reducing the amount of budget for local authorities. In the same time, the increasing return to the principles of public health signifies that a purely medical approach to health cannot by itself resolve the many health problems in increasingly complex cities. Government health strategy documents increasingly recognize the importance of the views of the people receiving services in needs-based service delivery and espouse the involvement of individuals and communities as a key objective in the future delivery of health services. To give people an effective voice in the shaping of the health services there needs to be a move away from one-off consultation towards ongoing involvement of local people. Healthy urban planning, in the simplest terms, should mean planning that (a) is not unhealthy and (b) promotes health. Factors affecting urban planning and health include: - high priority of urban planning and health in the political agenda; - monitor pollution level (air, water, outside and inside air pollution, etc.) and maintaining pollution under control; - plan, design and build urban areas focusing on people’s health (green areas, housing, availability and accessibility of health and social services, etc.).

153

chaos in several EU cities. “Public spaces become barren zones where gangs wage war.” 17 If a community does not have adequate health services, schools, libraries, recreational facilities or access to food and parks, the community loses a major buffer against violence. Without these critical institutions, not only is a buffer missing, but there is no community infrastructure and thus minimal opportunity for community cohesion, resulting in intensified fragmentation. This places urban planners in a position of great importance. It stresses the need for creating neighbourhoods that foster pride, respect and friendliness and ensure accessibility of services. It provides evidence of the importance of “liveable urban spaces located at the heart of the city or neighbourhood … [That] exemplify the essence of the community” 18 . There are, of course, many different opinions as to what constitutes a healthy city, depending upon one’s discipline, values and point of view. Nevertheless, general principles, theories and common parameters can be applied in working towards healthy urban planning.

The tools and techniques used to initiate an alternative, healthy urban planning process will undoubtedly vary from city to city, neighbourhood to neighbourhood and group to group. Whatever the overall process, it must take into account the various cultures, religions and lifestyles in the community. Healthy urban planning does not view multiculturalism and diversity as problems to be overcome but rather as rich opportunities waiting to be seized. Urban planning must be sustained by dynamic leadership styles and open to various configurations. For example, it should be open to collaborative and bottom-up actions. Healthy urban planning thus makes room for citizens as leaders and requires catalytic leadership from planners. Disadvantaged and marginalized groups are particularly at risk in urban areas. In order to ensure health for all, the standards of health must consider the most vulnerable

17 Duhl L. J. and Sanchez A. K. (1999), “Healthy cities and the city planning process”, WHO Regional Office for Europe, Copenhagen. 18 Cohen L. (1993), “A public health approach to the violence epidemic in the United States”, Environment and urbanization, 5, pp. 50–66.

154

populations. This approach is often used in the setting of environmental health standards. For example, the standard for the maximum allowable levels of lead exposure is set for the most susceptible population, in this case children. This concept relates to urban planners: “To create a liveable city for all the community, one must design for its weakest members, children, disabled and the elderly. A city that is hospitable to these groups will foster a sense of well-being among all its citizens.” 19

Health and health related issues can, thus, be considered to have a deep impact on the quality of life of the European citizens and this is especially true in cities, where social and environmental health determinants (such as those influencing lifestyle, the quality and quantity of available choices in terms of healthy choices, and health factors more directly linked to disease prevention, as in the case of nutrition, tobacco and alcohol) become key factors for urban policies, often without a direct legal competence of the city government in these issues.

The Building Healthy Community (BHC) Thematic Network thus focuses in creating opportunities for cities to shape healthy policies for their citizens by: - sharing knowledge and competences among partner cities; - co-operating with the Regional Managing Authorities of the relevant EU Structural Funds (being the Network a Fast Track); - investing in a bottom-up approach that leaves the decision-making process in the hand of Local Support Groups, while providing the support, methodology and toolbox to design the Local Action Plans.

19 Crowhurst-Lennard S.H. and Lennard H.L. (1987), “Liveable cities”, Gondolier Press, Southampton, NY.

155

of quality of life and lifestyle and in terms of providing good services to prevent illness or bad health conditions. The third theme referred to Structural Funds as a way to provide an exceptional tool to design strategies to implement health and quality of life conditions in cities and regions of Europe. The fourth theme, finally, regarded healthy places and healthy environment as crucial issues in cities that has to face problems of neglected areas, physical concentration of disease and inequalities and implementation of regeneration strategies that are highly time and funds demanding. An healthy environment is also determinant in defining the degree of quality of life in a city or in part of a city. A place could be, in fact, defined as “healthy” as long as it has actually an healthy environment and it is perceived as a safe, lively, clean, nice, active area.

156

general policies definition strategies so to let health and quality of life be considered as first class policies for the development of the EU. To this purpose, the theme will be considered as a transversal theme that will continue during the whole life of the project.

The Local Mappings prepared for the exchanges during the Phase 1 represented a great effort for all the cities, and sometimes the already associated MAs, to share a methodology and a greater opportunity to discuss among partners of health and quality of life related issues. In the LMs it is also possible to see how health and quality of life are differently considered in the different national context and in a broader division of North-Atlantic countries, Souther Europe and Easter Europe. Yet, it is clear that when it comes to priorities, needs and challenges the most important issue regards the citizens well-being and the definition of healthy and sustainable policies. In this case, the ten European partners showed a real shared view and a common interest. The results of this interaction are in the redefinition of the themes of the Thematic Network and in the already started process of discussion and debate at local level, thanks to the established Local Support Groups.

The redefined themes of which BHC intends to concentrate its efforts, each with a specific role in the 30 months lifespan of the implementation of the project, are as follows. The first theme focus on Indicators and Criteria for a Healthy Sustainable Urban Development . European cities are facing new waves of transformations due to demographic change, fluxes of internal and trans-national migration, economic restructuring and changes in the traditional Welfare State structure, to name some of the most important factors of change. Experiences in tackling these issues are witnessed throughout the EU, with similarities and differences in the processes of regeneration and development undertaken but still there is a lack of knowledge in two important and interrelated fields: iii. the relationship among these transformations, health and quality of life in cities and the promotion of a sustainable approach to urban development; iv. the capacity to measure this relationship, in order to monitor, assess and evaluate changes and policies that address these changes.

157

158