• REDUCTION OF HEALTH INEQUALITIES 1 IN LOVECH MUNICIPALITY – BULGARIA USING A HEALTH PROMOTION LIFE-COURSE PERSPECTIVE An Action Plan • 2 The region of Lovech is situated in North Central Bulgaria. The population size of Lovech region is 139609 people, 49% males vs. 51% females1, accounting for 1,9% of the total population. The demographic situation of Lovech region in terms of sex/age structure and downward population trends is unfavorable and worse than national average. The analysis of the three age groups (0 – 17, 18 – 59 and over 60) proportions shows that the first group has a very low percentage (less than 20%), while the third group has a high percentage of over 40%, thus demonstrating the aging population structure in Lovech region. The percentage of people living under the poverty line in Bulgaria is 21,8%, 3 • with this share being higher for Lovech Region – 23,9%. The proportion of the poor estimated by the poverty line in 2010 for the Lovech area is even higher, namely 23,9%. 66,6% of the population (men (69,9%) and women (63,8%)) are at risk of poverty or social exclusion in Lovech2. To compare, the total country’s population at risk of poverty or social exclusion is 49,2%, men (47,3%) and women (50,9%). Aging population, unemployment and deteriorated social status are factors that directly affect health status and increase incidence of chronic non- communicable diseases: cardiovascular, oncological, pulmonary diseases and diabetes, both at local and national level. The leading risk factors for these diseases are lifestyle factors, e.g. smoking, low physical activity, alcohol consumption, unhealthy nutrition & overweight/obesity and age (60 years and older), and could be influenced by health promotion and to some extent by the health system (timely diagnostics). The Regional Health Inspectorates have current data on all disadvantaged social groups, including the Roma community in the region, such as employment and educational level, routine examinations, immunizations, as a result of regional strategy monitoring activities. These data could be of help in developing and implementing the Action Plan on Reducing Health Inequalities. Facilitating factors for the Action Plan are the existence of the current Regional Strategy for Roma Integration (2012 – 2020), existing expertise, good training practices, commitment as well as NGO’s presence in the Roma community. Challenges that should be taken into account with respect to the 1 National Statistical Institute, 2011 Available at: http://www.nsi.bg/bg/content/797/ 2 National Statistical Institute, 2011 Available at: http://www.nsi.bg/bg/content/797/ implementation of the Action Plan are the organization and coverage of the Roma population and the lack of health mediators for the Roma population in municipalities. Other barriers are uncertain funding, lack of mechanisms to involve physicians in the Action Plan and a poor coordination between institutions. In order to implement the action plans, an active participation of municipalities and sufficient human and financial resources are needed. The situation described above and the new programming period (2014 – 2020) for the Operational Programme Human Resources Development necessitates further specification of the established priorities so that • 4 national goals are achieved. They suggest significant, measurable and sustainable progress in reducing the high risk of poverty and social exclusion faced by Bulgarian citizens. Particularly important is that such progress be reached within a certain category of regions (less developed regions). In order to address the majority of the preconditions for the exclusion of the target groups from the labor market and public life, an integrated approach is required. Over the past few years, the financial and economic crisis has exerted a significant negative impact on the most vulnerable groups in Bulgarian society. In terms of economic status, the risk of poverty is highest for the unemployed, pensioners and the other economically inactive persons. Mostly affected is a large part of the Roma community living isolated and in very difficult living conditions. Ensuring access to basic health and social services is a key tool for overcoming the effects of poverty and social exclusion. Operational Programme Human Resources Development emphasizes on the following: improving access to employment, education, social and health services for the Roma, a targeted and integrated approach to vulnerable citizens of Roma descent, not necessarily excluding the provision of support to disadvantaged persons from other ethnic groups, the disabled as well as people at risk of discrimination and other forms of social exclusion, the homeless or those living in poor housing conditions, people with addictions, children, youth and families at risk and other people or groups in need of support. In compliance with the requirements of the Operational Programme Human Resources Development, the current Action Plan covers only activities aimed at improving the quality of life and ensuring sustainable integration of marginalized communities. It takes into account the reasons for the selection of thematic objectives and investment priorities under the Operational Programme Human Resources Development (2014 – 2020). Its main objectives can be viewed as a specification of the thematic objective “Promoting social inclusion and combating poverty”. Planned actions are consistent with its priorities “Integration of marginalized communities such as the Roma” and “Active Involvement”, whereas leading role play two directions: “Improving access to employment” and “Access to social and health services”. Of the activities defined as key in the OP “Human Resources Development”, namely providing access and delivery of quality health and social services and improving access to healthcare and 5 • enhancing health culture of marginalized communities, including through health awareness campaigns, the primary focus is placed on the second key activity. The Action plan aims, through health promotion, to impact on health inequalities, both on regional and national level. Five objectives have been highlighted, each of which has been justified and includes specific objectives, activities and indicators for their implementation. The key concepts for the strategy and action plan implementation are listed below: Viewed as a contribution to society and the long-term benefits to it, the project GOAL is to affect health inequalities on regional and national level (for example, reducing mortality from cardiovascular, lung and oncological diseases as well as reducing health inequalities across different social groups of the population). OBJECTIVES are more specifically defined areas to be affected, for example, related to the needs and situation of certain target groups. PLAN TASKS represent the next level of specification following objectives and how they will be achieved has also been defined. SPECIFIC OBJECTIVES describe the actions, the expected outcomes as well as the related deadlines. Their implementation can be quantitatively measured. The INDICATORS are selected so as to measure not only the advancement to the preliminarily set goal, but its efficiency and sustainability of achievements as well. PRIMARY GOAL: REDUCING HEALTH INEQUALITIES BOTH WITHIN THE REGION AND BETWEEN IT AND THE COUNTRY THROUGH HEALTH PROMOTION As already mentioned, we can observe health inequalities both within the regions of the country and between the regions themselves. The interregional health inequalities are differences in the health status of the population in the various regions. The population of the region as a whole can be considered a risk group of adverse health status compared to the the population of the central regions. This is expressed, for instance, in • 6 lower life expectancy in the region. Differences in the health status of the population reflect health inequalities in the region. Examples of adverse health status risk groups are the persons with low education, the unemployed, the elderly and the ethnic minorities. These groups are characterized by a significantly higher risk of adverse health outcomes. One of the goals of the present action plan is that the health status in the region be as close as possible to the one in the central regions, with the regional population and, in particular, the vulnerable groups being supported in building healthy behavior and environment. AIM 1: PLACING HEALTH INEQUALITIES IN THE PUBLIC SPOTLIGHT. CHANGE IN THE LEVEL OF AWARENESS, KNOWLEDGE AND ATTITUDES OF INDIVIDUALS TO THEM Community and its members must possess a certain level of awareness and health knowledge as “a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity”3, and make it a priority so as to enable work on reducing health inequalities. The health model recommended by the WHO indicates that health is affected by a number of factors4. They range from genetics and individual lifestyle to macroeconomic, social, cultural and environmental conditions, 3 According to the WHO definition. 4 Age, gender, hereditary factors, individual lifestyle, social and community influences, working and living conditions, socio-economic macrofactors, cultural and environmental factors. with social cohesion playing a key role, particularly in vulnerable communities. The overall health responsibility is shared between the individual, the family, the community, the administration at all levels and