WHO Regions for Health Network: Second Regional Ministerial Forum: Venice, Italy, 15 December 2003

WHO Regions for Health Network Second Regional Ministerial Forum

Venice, Italy, 15 December 2003

English only

ABSTRACT The importance of regions in health development is increasingly being recognized in Europe. As regions are close to their populations, have a close understanding of local health problems, and have the capacity to allocate resources for action, the regional level is ideal for health policy development. Regions in many countries already have considerable responsibilities for health and health care, while others are acquiring them through the process of devolution. The Regions for Health Network (RHN) of the World Health Organization, recognizing these developments and their importance for health improvement, organized the Second Regional Ministerial Forum in Venice to take advantage of the momentum generated by the first held in Copenhagen in June. High-level representatives heard and commented on background presentations on the new WHO European Office for Investment for Health and Development, health systems decentralization in Europe, and health information and regional cooperation. It was followed by a round table discussion on important issues for the future of the Network, after which ministerial representatives agreed to sign the Venice Declaration that set out the RHN’s work programme for the biennium 2004–2005.

Keywords REGIONAL HEALTH PLANNING HEALTH POLICY HEALTH PROMOTION DELIVERY OF HEALTH CARE – trends INTERNATIONAL COOPERATION CONGRESSES EUROPE

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CONTENTS Page Opening session............................................................................................................................1 Welcome by the Minister of Health for Veneto Region..................................................................1 Welcome by the Regional Director of the WHO European Region ...............................................2 Greetings from the European Commission ...................................................................................3 Presentations ................................................................................................................................4 Regions and the WHO European Office for Investment for Health and Development.........4 Health systems decentralization – The role (and challenges) for the regions......................5 Health information and regional cooperation – experience of the Health Behaviour of School-Aged Children (HBSC).........................................................................................7 The round table discussion ...........................................................................................................9 Introduction ..........................................................................................................................9 Contributions ......................................................................................................................11 Response by the Regional Director of the WHO European Region............................................14 Adoption and signing of the Declaration and Conclusion............................................................14 Annex 1. Venice Declaration of the RHN ....................................................................................15 Annex 2. Final list of participants.................................................................................................28

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Opening session The meeting was opened by Mrs Wendy Tse Yared, Coordinator of the Regions for Health Network. The participants elected Dr Marc Danzon, the Regional Director of World Health Organization (WHO), Regional Office for Europe and Dr Fabio Gava, the Minister of Health of the Veneto Region as joint Chairpersons, and Dr Chris Riley from the United Kingdom as Rapporteur. The agenda and programme of the Forum were adopted. Dr Gava provided the official welcome. Mrs Wendy Tse Yared welcomed the political representatives from 28 regions across Europe. This meeting would continue the momentum started in June at the First Regional Ministerial Forum, where basic principles were agreed on areas of joint working. A main item for the round table discussion later in the session would be the proposed work programme for the two years 2004–2005 based on these principles. The work programme had been approved during the Network’s Annual General Meeting in Teplice in the Czech Republic in November. Member regions had then agreed to focus on activities that would help define good regional health policy, generate evidence and tools, and provide new knowledge to support the common goal of the regions and WHO – to improve the health of Europe’s citizens. On behalf of the Network, she thanked the Regional Director for his support in attending the meeting, the Veneto Region for their generosity and hospitality and the Veneto focal point, Dr Luigi Bertinato, for organizing what would be an important forum.

Welcome by the Minister of Health for Veneto Region Dr Danzon took the Chair and introduced Dr Fabio Gava, Regional Minister of Health of the Veneto Region one of the hosting partners for the WHO European Office for Investment for Health and Development. Dr Gava recalled that a year prior to this event in Palermo in Sicily, regional ministers had assembled for the first time to celebrate the 10th anniversary of the Regions for Health Network (RHN). He was delighted that so many were able to attend this meeting in Venice. The Palermo meeting was followed by the First Regional Ministerial Forum held in Copenhagen, hosted by Dr Danzon at the WHO Regional Office for Europe. Dr Gava welcomed Dr Danzon and his colleagues from the WHO to Venice as well as ministers and officials from regions across Europe. Issues such as cross-border health and the free movement of patients and health professionals were raised in Palermo and again considered during the Italian Presidency in the second half of 2003 as suggested by the Italian regions. Health issues in an enlarged Europe were defined as being important not only for countries, but also for regions, considering that the RHN regions present at the Ministerial Conference in Venice represented some 80 million people from across Europe. Health issues underlay differences in the social development and social security system of Europe, and these had gained in importance now that the concept of an enlarged Europe was becoming ever more consolidated. Rapid economic development had caused difficulties, especially in some of the countries that had previously been outside the European Union that were now joining, the reason

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being they were now receiving collaboration. WHO recognized the strong links between social and economic development, and this was the reason that the Network needed to encourage Regions to share their ideas, and give the European Union the benefit of their views and experience. The enlargement of the European Union will also have long-term effects on human health due to the high level of inequalities in health services provision and access, especially in those services provided directly by the Regions. A further point of discussion related to the appropriate way of dealing with health care. The Venice Ministerial Conference will be of vital importance to set up a forum for debate where Ministers regularly have the opportunity to meet and discuss about European political health issues. Debates involving the regions could help make more informed decisions within the European Union and in European Institutions. The Veneto Region congratulated Dr Danzon on his and WHO’s support for organizing this event. The future working programme of the RHN would be discussed at length among the 24 delegations attending the meeting. During this meeting, a number of projects to be developed in collaboration between the Regions of the Network would be presented, including the Investment for Health strategies. This meeting offers an occasion to discuss the opportunity to work in close collaboration with the European Observatory on Health Care Systems with the aim of developing a comparative study on the decentralization of health care systems in Europe. Dr Gava concluded by thanking again all those present for attending and contributing.

Welcome by the Regional Director of the WHO European Region Dr Danzon expressed his pleasure at seeing so many regions present – more than in Copenhagen in June. It was important to have such meetings, not too often perhaps, but certainly regularly. A network should meet and exchange views. The view is gaining ground that the region is the right size for many functions, so it is a good time for the Network to become stronger. But it must also be clear. WHO’s constitutional relationship is with ministers of health at the national level. That must not change, but as Dr Gava said it is good for countries to have strong and well functioning regions. Countries will come to appreciate the benefits of having a network of strong regions supporting health improvement. In Copenhagen, Dr Danzon had issued a challenge to the Network, and he did so again. Two points were proposed for the agenda. The first was to make clear the role of regions in relations to health policy, health systems and health professionals – what can and should be done, and how? These issues are on the national agenda, and should also be on regional agenda. There needed to be transparency and guidelines on who would do what. The second was for all parties to draw together knowledge on public health issues, and make it known wherever it might be useful.

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Through working on these two issues, the Network could be truly beneficial to those beyond its membership. The proposals were noted in the work programme: • • • • • • • •

alcohol and drugs – a topic of worldwide concern and high on the Agenda of the WHO Regional Office for Europe; cross-border issues – a cause of concern for many countries; Investment for Health – an obvious issue for the meeting in Venice; regional indicators – essential when information is so often lacking, and especially important when more local sources offer better quality and relevance; policy development – also essential for the Network; Roma health – a good example of equity and solidarity; quality – this was especially noted, as perhaps the future prime focus for WHO – to ensure that more is achieved from the limited resources available; health impact assessment – also a major theme.

All were crucial. Enlargement would be vital to all 25 of the European Union countries – and to their regions. The issue of mobility would also be vital to them all. A regional network could therefore perhaps usefully work closely with the EU. But he also noted that many of the countries in the WHO European Region would still be outside the EU, and WHO must work with all. These too would need strong support, and he urged the Network to help them.

Greetings from the European Commission Dr Gava then introduced Dr Zanon, who was speaking as a national expert from the Veneto Region and tendered the apologies of Bernard Merkel and Tapani Piha of the European Commission, who were unable to attend. On their behalf, Dr Zanon offered greetings and support from the European Commission and passed on the regret of Mr Fernand Sauer, the Director for Public Health in the Directorate General for Health and Consumer Protection at the European Commission, that he could not attend the meeting, which would address some of the most important health policy issues facing Europe. Regions are increasingly important in the area of health care and the Commission had supported several projects under the public health programme that addressed their role in health. These had provided information about the similarities and differences between regions and highlighted the possibilities for future action. One example was the EVA project, which had found great heterogeneity among published regional and national public health reports. The project team had concluded that development of common methods for preparing reports would increase the attention the reports attracted, and improve their usefulness in the policy-making process. The Commission, believing that sharing experience and knowledge will benefit all involved, offered full support to the collaboration between the regions in the Network and looked forward to working with it. It was also expressed that Commission representatives could participate in future meetings.

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Presentations Three presentations were made on important background issues relating to the work of the Network. Regions and the WHO European Office for Investment for Health and Development Dr Erio Ziglio, the Head of the WHO European Office for Investment for Health and Development, presented this topic as the link between the work of the RHN and the work of his new Office opened that morning. Regions are clearly acquiring a greater role in planning and administration. Both regions and the Venice Centre are interested in linking health and social development, and therefore there is a very good basis for joint action. The inclusion in the work programme of a project on Investment in Health was not a surprise as that was already the title of the health policy of North West England, the region that would be leading the project. The Venice Office is very interested in pragmatic collaboration, and would want to encourage case studies; help develop and provide methods, tools and know-how to support action to improve health; and organize learning opportunities and training for health managers and regional decision makers. Dr Danzon queried the type of case studies the Venice Office might undertake with regions as against those at national level. Dr Ziglio cited the example that North West England is aiming to reduce health inequalities and said that the Centre could help analyse their activities and results. Another possibility would be to work with say five or six regions and compare how they were trying to raise the importance of health inequalities in overall policy-making. Dr Danzon wondered whether it might be possible for the Centre to follow up its publication on action through health systems to tackle poverty, for example by improving access, with a second on action at the regional level. Dr Ziglio reflected that it would be very useful to do so – to complement information already available at the national and the local level. North West England added that much had been done in the region to improve health. The main determinants of poor health were economic, social and cultural and the region was aiming to tackle these through action on housing, jobs and the general economy; through health and social care; and through using its economic influence as a major employer. Dr Ziglio said that other regions were also interested in such action, and the power of regions as employing and purchasing organizations needed to be explored more fully. There was a general understanding that health and economic factors were linked – the issue now was to identify more clearly what needed to be done. He wanted to collect and analyse some concrete examples. Dr Ziglio reiterated that the Venice Office is indeed ready to work on the project proposed by North West England and with the involvement of a few more very committed regions. The project is seen by the Venice Office to have very clear outcomes and products which include: analysis of Investment for Health tools and methodologies, know-how transfer and development; and the development of a training and skill development package that could be used to disseminate the learning from the project throughout Europe. Wales supported that targeting poor health was a strong policy aim and said it would be very important for the Centre to act as a channel for sharing learning and outcomes. Wales had

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reformed the funding allocation process to target the areas with the worst health and was looking for measurable health gain especially in relation to heart disease. Health systems decentralization – The role (and challenges) for the regions Dr Josep Figueras, Head of the European Observatory on Health Care Systems and Policies at the WHO Regional Office for Europe, presented the work of his office as one centred on gathering evidence for effective action in the health field. He felt particularly pleased and privileged to be making his presentation in Venice, as the Veneto region had always been a great help to and a strong collaborator for the Observatory. Four issues were addressed. • • • •

What did decentralization mean? It was more than just a trend involving regions. What issues did regions face? The issue of stewardship as a common thread linking the changes. The potential role of evidence and of the Observatory.

Decentralization is not a single simple process but can take a number of forms, and four different types were used. The first was “deconcentration” – the transfer of administrative tasks and functions to a lower tier – to regions, counties, provinces and municipalities. This might in some circumstances be interpreted as a form of centralization of power if it served to give the higher level more control over the lower. The second was political devolution, passing authority down to the lower level. The third was delegation of tasks, which might for instance be passed out to social health insurance bodies or to professional regulators. The fourth was privatization, which could be to profit-making or not-for-profit bodies. Within health systems the decentralizing tendency is evident, in a number of ways. One is a shift in the balance of roles between the state and the market, provoking a need to develop the stewardship role of the state. Another is the development of social health insurance systems in the countries of eastern and central Europe and the former Soviet Union. Political devolution is strengthening the regional and municipal levels. Different approaches to the purchaser/provider split have led to the development of strategic purchasing, selective contracting and activity-based payment systems for providers. Provider decentralization has taken the form of self-governing hospitals, public trusts and foundation hospitals, the latter a case of an idea from the United Kingdom being adopted by Spain and then re-adopted in its new form back into the United Kingdom. Another development is the increased role of the private sector, e.g. the increase in private primary care and dental practitioners. A linked process is the growth of patient empowerment. This can take the form of a stronger voice – as through representation or the patient rights movement; a strengthened right of “exit”, with increased choice over which provider to use; and mobility of both patients and service providers within the European Union. Countries and regions face considerable challenges, such as avoiding duplication, fragmentation and poor coordination; keeping down transaction costs and achieving economies of scale; maintaining parity of quality, in the face perhaps of substantial volume variations; ensuring equity of access and coverage; enforcing accountability; and providing adequate local capacity.

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Movement of control up a tier had also been happening. In Sweden, some counties had been merged in what was effectively a form of centralization. In Germany, efforts to contain costs had led to greater government control of social health insurance bodies, and in Hungary, these had been returned to government ownership. In Estonia, Hungary and Poland regional funds had been merged. The decisions of the European Court of Justice on patient and service mobility could be seen as a form of centralization of decision-making to the European Union level, taking power from both regions and the state. So there is not a one-way process; both decentralizing and recentralizing tendencies are visible. Indeed Norway had seen both, as its hospital decentralization had subsequently been reversed. Regions clearly represent an important element of decentralization, but they are not uniform. There is great diversity in size, models, powers and tasks. Their competence might or might not include planning, funding (collection and pooling), purchasing and provision. The situation depends on decisions outside their own control. Their role must fit into the overall structure and working of the state, and is essentially a political decision. An important criterion must be to ensure that their functions are coherent, and, of course, further changes can always destabilize the situation and create incompatible functions. In this situation Dr Figueras again raised a question he had posed the Network in a previous meeting – with the diminution of the powers of the nation state, were regions the new “stewards”? In other words, would they take on the role of ensuring that the many elements within the health system work in concert and take responsibility for instance for: • • •

policy leadership regulation; and managing information and intelligence about health issues?

Without good stewardship, performance would deteriorate. If the national level gave up responsibility for “vertical” stewardship, there would be a need to develop “horizontal” interregional or shared stewardship. So there will be a need for regional health policy leadership. Evidence suggests that that topdown health policy development is insufficient, and that there is a role for regional health policy and planning. There are many regional health targets, for example in Swedish counties, German Länder, Spanish autonomous regions, and French regions. Important public health functions can also be exercised at that level, including health needs assessment. In terms of interregional or shared regulation, there will be a need to clarify the management of central regulatory functions, such as regarding new drugs and training standards; establishing a financial redistribution formula; creating a standardized basic benefit package; accreditation of providers; and regulating and managing patient mobility at the regional, national and European Union level, linked to the provision of centres of excellence. Regarding intelligence and steering the system by means of information, issues to be tackled include providing technical support for information development, benchmarking and standardization of databases and indicators; identification and diffusion of innovations; learning from “natural experiments” and redistributing knowledge from rich to poor regions.

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Making all this happen requires the creation of interregional stewardship mechanisms such as an interregional agency to share responsibility and evidence; accepting that development must be incremental; and creating capacity, credibility and transparency in the system. There would need to be cross-regional transfer of the essential know-how and genuine interregional collaboration. This would not be easy, but would be necessary. He turned to what the Observatory could do to help. One possibility would be to produce regional profiles, perhaps something similar to the “Health Systems in Transition” (HiT) profiles currently produced for each separate country in the European Region. The HiTs included a country overview, and analysis of organizational structure, finance and expenditure, health care delivery, financial allocation system and reform processes. The Observatory had also produced analytical studies in areas such as regulating entrepreneurial behaviour, the appropriate role of the hospital, options for the funding health care, purchasing for health gain, putting primary care in the driver’s seat, human resources for health, mental health and pharmaceuticals. A new set of studies on decentralization in health care would be considering both strategies and outcomes, and would aim to map decentralization strategies, evaluate their impact across a range of societal objectives, assess implementation processes and explore options for policy-makers. Health information and regional cooperation – experience of the Health Behaviour of School-Aged Children (HBSC) Professor Klaus Hurrelmann from the School of Public Health in Bielefeld, North Rhine Westphalia, Germany, said that, as a developmental psychologist and social scientist with an interest in child health development, he had observed that young people’s health had in recent years been moving in a new and dangerous direction. He urged his audience to take two steps. The first is to take children’s health seriously – urgent action is needed to avoid a health catastrophe. The second is to establish and use an information and monitoring system, so that they can understand trends and support effective action. Health Behaviour of School-Aged Children (HBSC), a cross-national research study conducted in collaboration with the WHO Regional Office for Europe, is an example of what could be done. It is a study based on a self-reporting system and has been in use for 20 years, providing data of considerable epidemiological importance. It can support monitoring, benchmarking and health improvement and is a valuable source of evidence on health inequalities. Lifelong inequalities start at a very early age. The study aims to gain new insight into, and increase understanding of young people’s health and well-being and health behaviours and of their social context. In addition, the findings from the HBSC surveys are used to inform and influence health promotion and health education policy and practice at national and international levels. Research into children’s health and health behaviour and the factors that influence them is essential for the development of effective health education and health promotion policy, programmes and practice targeted at young people. It is important that young people’s health is considered in its broadest sense, encompassing physical, social and emotional well-being.

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Health should be viewed as a resource for everyday living, and not just the absence of disease. Research into children’s health therefore needs to consider positive aspects of health, as well as risk factors for future ill health and disease. Family, school and peer settings and relationships need to be explored, as does the socioeconomic environment in which young people grow up, if patterns of health and health behaviour are to be fully understood. The main finding from the data collected is that health status is related to behaviour and behaviour to lifestyle. It is evident that behaving in a healthy way is not fashionable – especially among poor children. Professor Hurrelmann picked out four issues. • •

Children have become inactive and exercise rates are low. Children no longer come to grips with their social and physical environment. Dangerous nutrition patterns have emerged, quite unsuitable for developing bodies. Fast foods are the fashion, and peer pressure reinforces this. Being overweight is becoming more common; in Germany among some groups 15% of children are obese. The problem is especially common in the less favoured social classes. Young people no longer have adequate coping strategies. They cannot deal with frustration and poor environments. Smoking has emerged as a coping approach, and after falling for ten years alcohol consumption is on the rise. Childhood has been compressed. Puberty is occurring earlier, down from the age of sixteen and a half years in the 18th century to eleven and a half now and still falling. Children are thus more emotionally challenged and face developmental arousal at an earlier age.

•

•

Lifestyle is related to the social situation, as are health inequalities. The result is even lower activity, poorer nutrition, and more smoking, obesity and illness, and increased use of health services. Social inequality among children is very important. Society must respond through health promotion, education and policy action. Unfortunately the “prevention programme dilemma” means that most programmes don’t reach the most deprived groups, who manage to isolate themselves from them. This underscores the vital need for a sound survey approach in every region. HBSC provides intercountry and interregional comparisons, offering an insight into health status, behaviour, lifestyle and context. The target population of the HBSC study is young people attending school, aged 11, 13 and 15years-old. These age groups represent a period covering the onset of adolescence, the challenge of physical and emotional changes, and the middle years when important life and career decisions are beginning to be made. HBSC is a school-based survey with data collected through anonymous, standardized selfcompletion questionnaires administered in the classroom. Fieldwork for each cross-national survey is carried out over a period of around seven to eight months, from October to May of the following year. This reflects the sampling strategy used in each country in order to achieve the mean ages of 11.5, 13.5 and 15.5. The HBSC survey instrument is a standard questionnaire developed by the international research network and used by all participating countries. Each survey questionnaire contains a core set of questions looking at the following:

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• • • •

background factors: demographics and maturation, social background (family structure, socioeconomic status); individual and social resources: body image, family support, peers, school environment; health behaviours: physical activity, eating and dieting, smoking, alcohol use, cannabis use, sexual behaviour, violence and bullying, injuries; health outcomes: symptoms, life satisfaction, self-reported health, body mass index.

Many countries also include additional items in their national questionnaire that are of particular interest on a national level. Dr Danzon asked for examples of how children now are different from those of the 1950s. Professor Hurrelmann replied that a major change is the huge reduction in childhood illnesses. Unfortunately, this good news is offset by an increase in immune deficiency problems. Immune systems seem to have become weaker, and there are unresolved links to eating disorders, inactivity and a failure to develop a strong mind and body.

The round table discussion Introduction Dr Gava took the chair for the second part of the meeting, which would lead into the round table discussion. He first invited Mrs Cornelia Prüfer-Storcks, the Secretary of State for Health, Social Affairs, Women and Family of the State of North Rhine Westphalia, to speak. Mrs Prüfer-Storcks thanked Dr Danzon on behalf of the Regions for his attendance at the meeting and thanked Minister Gava for his superb hospitality. It was a very happy coincidence that the meeting should take place alongside the opening of the Venice Office. The intention of those present was to link clearly the strategy of the RHN to the future development of the European Union, and this represented a major opportunity for both. From her region’s point of view the Network offered great potential: • • •

to support regions in tackling challenges at the European level; to encourage learning and development within the regions through knowledge transfer and benchmarking; and to contribute to the development of the regional dimension in Europe.

She introduced the four items on the agenda for the round table discussion: • • • •

enlargement of the European Union mobility of patients the role of regions in Europe and the European Union the future role and work programme of the RHN.

Enlargement of the European Union will have a huge impact. As a result there will be 15 members instead of 25, there will be 20 official languages instead of 11, and the total

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population will rise from around 375 to around 480 million. New borders and new border regions will be established, and health policy will face new challenges both within and outsides the European Union. There will be repercussions for all, and sharp challenges that regions across Europe and the Network in particular will have to face. One result will be the existence of real and important gaps between the old and new countries in health status, health risks and health care. Life expectancy will vary by up to seven years, and there will be marked differences in infant mortality. The distribution of risk factors such as smoking rates, diet, and alcohol consumption will differ considerably. And the social situation is continuing to change everywhere. There will be worrying gaps in health resources and expenditure – with health-related expenditure accounting for 4.5% of gross national product among the new members of the European Union as compared to 8.6% among the existing members. Many countries are trying to increase the percentage but cannot assume that more resources will increase quality. As a consequence all must try to share knowledge. Network members can improve and enhance services and so improve health. However, not all differences should be abolished. Coming together should be the result of definite decisions, not just through following others. Standardization of health services could cause a problem in Germany if the European Union tried to make everyone the same, through running up against the question of sovereignty. Patient mobility has only recently attracted attention in discussions at the European Union level and between European Union member states, as the European Union has in the past primarily dealt with questions of health protection and problem prevention. It is mainly the rulings of the European Court of Justice that have caused the change. The fact is that patient mobility has increased with tourism, in border regions, through more people spending longer stays abroad and because specific services or services at lower cost or with less delay are available in another country. The result is greater competition, and that is good as it provides the opportunity to learn from good – and bad – practice elsewhere. This also prompts the need for better information, especially to provide greater transparency about services and their quality for patients who travel across borders for treatment. So comparable data becomes essential. In addition, administrative cooperation will have to improve, and the Network will need to pay attention to discussions at government level within the European Union on this issue. Regional cooperation makes a lot of sense and can lead to concrete improvements. The role of regions in Europe and the European Union will continue to develop. The German Länder have long had specific significant responsibilities in the field of health and in other countries too decentralization has increased. Within the new Europe, arrangements are needed that can be easily used and understood by citizens, and it is already at the regional level in many countries that health policy is shaped and implemented and directly experienced by patients. Moreover, experience already shows that regions can often be more flexible and innovative than the national level. The creation of the Network 11 years before had been a cutting edge development, and cooperation at the regional level will remain of central importance for the European integration process.

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The final topic was the Network’s future role and work programme. The new work programme would be the basis for intensified cooperation within the Network and met the commitments made in Copenhagen. It also offered a basis for close cooperation with the European Union and its programmes. The project that North Rhine Westphalia had undertaken to lead would provide a new information base for the Network in close collaboration with both WHO and the EU. Comparable information would be essential for rational cooperation, for the exchange of experience and for learning from each other. Another proposal related to an earlier project – BEN, which had aimed to getter a better insight into regional health information systems and their management and processes. A bid for funding for a follow up project – BEN2 – had been made to the European Union to look at breast cancer and diabetes. The regions were invited to join this project. In concluding, Mrs Prüfer-Storcks stressed to Dr Danzon that the commitments made in Copenhagen could only be fulfilled if the WHO Secretariat were equipped with the necessary means to serve as a reliable partner and supporter of the Regions, and that it would need to be strengthened in terms of resources. Contributions Dr Gava then invited others to speak. North West England spoke in relation to two issues – Investment in Health, one of the topics in the work programme, and the role of regions. The main determinants of poor health were not medically related – though obviously health services can do a great deal to alleviate health problems – but economic, social and cultural. That region had been a cradle of the industrial revolution and the factory system, and the decline of heavy industry had left a legacy of poverty and poor health. There was a 10 year difference between the life expectancy in the cities and affluent areas. The point made earlier about a three-point strategy was re-emphasized. Health and social care professionals need to recognize the importance of social and economic determinants of health, and work together and with other agencies to cut health inequalities. Communities need support to secure work, homes and security. Regions need to use their economic power as employers and purchasers. They must intensify their efforts to help hard to reach groups, ensure services support families and make jobs available wherever possible. Dr Gava then contributed to the discussion on behalf of his own region, Veneto. His region attached great importance to the opening of the Venice Office, as it had such an important role. It would be looking at the determinants of health, why some people are marginalized in relation to their health and – most important – what could be done about this. This would be extremely useful to governments. All were increasing spending on health, as the public value health and have rising expectations. By contributing to help improve health through better understanding, the Venice Centre would have a hugely significant role. The second point related to the Network and the Declaration that all were to sign at the meeting. This would cement the relationship between the regions and the WHO, and assist the members in exchanging views. Furthermore, since the Network contained members from both within and outside the European Union, it would give a better insight into what is happening across Europe and help feed back into European Union decision-making more generally. The WHO link represented a dimension that could support developments that otherwise might not be possible.

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The Network enables all involved to get a better understanding of the issues through an open and constructive process, and the Declaration would create the opportunity to come together through annual meetings. As a result health policies in the regions would be better and this in turn would assist their home countries to function more effectively. Timis County in Romania introduced itself as a county on the border of Hungary and Serbia and Montenegro and the first Romanian region in the Network. It had partnership arrangements with North Rhine Westphalia and Baden Würtemberg and had formed a cross-border Euro-region including regions from Hungary, Romania and Serbia and Montenegro. Timis expressed gratitude to the Veneto region, with which it had signed a protocol agreement in 2002, for its help in arranging for the county’s attendance at the meeting. Many Italians live in Timis and representatives of the regions had exchanged visits. Timis concluded by presenting Veneto Region with gift from the county – a lion – the symbol of both Timis and Veneto. Carinthia expressed pleasure at being present as the Network’s newest member, for the first time. Carinthia was extremely pleased that a neighbouring region would be hosting a WHO Centre, and felt this to be a sign of WHO’s willingness to get close to the people of Europe. Carinthia fully supported the two year work programme, and especially the proposal on crossborder collaboration. There was already cross-border cooperation between Carinthia and neighbouring Italian regions Friuli-Venezia-Giulia and Veneto. Especially relevant were the project “trans-border cooperation in patient care” with Friuli-Venezia-Giulia and joint work in the area of prevention. The driving force for health policy development will need to be at regional level, as it is much easier there than at national level. An important task of the Network should be to ensure that national and community institutions are well informed so that decisions made on health issues can be fully implemented. This will be necessary to ensure that all citizens get care of equal quality and that cost reduction efforts do not create problems. Carinthia is working with Slovenia and Italy on a number of cross-border issues. A project called “trans-border practical training” including a student exchange programme within the areas of health and nursing education has recently been initiated with the Veneto region. Currently, arrangements for the creation of a common basic and advanced education and training centre with the two mentioned Italian regions are being made. These trans-regional activities will also be expanded to Slovenian regions after the accession of Slovenia to the European Union in May 2004. Carinthia wants to hear of others’ activities, especially regarding quality, and it has established links with South Tyrol. The involvement of politicians should strengthen the Network, which can be an international platform for further development. Wales spoke about the regional role and the future of the Network. Wales was a founding member of the Regions for Health Network, and some of the ideas underlying it had been developed in Cardiff in 1991. People from Wales have done a great deal with and for the Network in the past. Wales has shown its commitment to the Network and still believes in it. But it recognizes too that the RHN faces a number of challenges. • •

It must have a clear role. It must make a real difference for all its members.

EUR/04/5045399 page 13

•

It must have a sound organizational and financial basis.

The new work programme does create a distinctive set of task for the Network. Wales has agreed to lead on the policy development project. All should share their experience, and the range and depth of policies in the Welsh 10-year programme to improve health in Wales gives it a good understanding in this area. It has clear health gain targets. Its aim is a health service, not a sickness service, and it is committed to pursuing better health through all its policies. Wales offered to use its considerable experience in the field of health impact assessment to help develop a project on that topic also. Seeing these projects through successfully would benefit Wales and others. But to have sustainable, long-term success for the Network requires a clear identity, a sustained purpose, and a sound organizational and financial basis. The regions needed to play our part, and so did WHO. The present arrangements had served the Network well for its first 11 years, but this is now a different Europe, with new members. There might need to be changes – some suggestions were: • • • •

replacing the Steering Committee by a Board establishing a Chair with a clear role agreeing to a five-year development plan with appropriate monitoring putting the budget on a firmer footing.

While there are several organizations representing European regions, the Network is the only one focused on health and closely linked to WHO. If the regions seriously want to work together to improve health, they need to ensure that the relationships are right and the foundations are strong. Wales suggested that an early task for the Steering Committee should be a careful review of the current arrangements. Östergötland spoke on belief both of its own region and for Västra Götaland. The two regions share both the goals of the Network and a belief in its future. It said that the work programme contained eight well focused projects, all on high priority issues, which showed that the Network had met the challenge put to it in Copenhagen. Their outcome would help diminish the differences in health and service levels between the older European Union countries and the rest of Europe. It was very important that all should cooperate on this. However, it was also important to recognize that the threats that lay ahead. The uncertain financial situation in the Network might make difficult delivery of the work programme. Regions would do what they could. The strong commitment expressed by ministers and Dr Danzon gave confidence that WHO with the regions would work together to tackle problems that might appear, and so ensure that the work programme was delivered. Valencia expressed that though in recent years it had been unable to participate very actively in the Network, it had continued to contribute its subscriptions and its minister had signed the Adoption of Principles. At the Annual General Meeting in Teplice there had been alternative solutions proposed which would not require more funds, such as a stronger Secretariat, possibly through regions seconding officials and paying their salary. The issue was not simply finance, but finding new sources and strategies to support the work of the Network.

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Dr Gava thanked all who had made contributions to the discussion, and concluded that the round table had been very encouraging and provided an optimistic view towards the future.

Response by the Regional Director of the WHO European Region Dr Danzon reminded the participants that at the Copenhagen meeting, he indicated that he wanted to make an agreement with the Regions – each side should be very clear on what it should do, and do it. The budget of WHO had not been increased in ten years, though over that period the number of countries in the European Region of WHO had grown by 20, and the budget had been eroded by inflation. While the Regional Director would have liked to allocate more resources for RHN, it would be impossible to promise in the current situation. He would like to consider different arrangements as Wales and Östergötland had proposed. After 11 years of life, the Network was in a different environment. It must look hard at its present situation, as regards both its members and those interests outside it, select carefully the tools to enable it to promote its objectives, and ask for the help it needs. WHO is not in a position to allocate extra resources from its regular budget. Additional fundraising efforts from voluntary sources could only be successful where there were well defined objectives and clear projects. The Regional Director would be ready to discuss further steps with the Network, perhaps reorganized along the lines proposed by Wales, with a clear programme and clear outcomes. He promised to do his best to support regions in their resource mobilization efforts along these lines. Unfortunately, assessed contributions from Member States to WHO have not increased while demanding actions on diseases such as SARS, on poverty and other areas have increased. It is not possible for WHO to do more with less resources. The former WHO Director-General, Dr Brundtland, had asked Member States for a small increase in the budget but this proposal was not accepted. In the face of rising costs, he appealed to the regions to press their own governments to generate more resources for WHO’s work and accept that otherwise WHO cannot meet all additional needs and requests. In these circumstances, WHO could not provide more services to the Network. Dr Gava thanked Dr Danzon, and proposed that the Network accept this new challenge and see how to stimulate more income. He asked all to take this very seriously.

Adoption and signing of the Declaration and Conclusion Dr Gava then moved that the Venice Declaration be adopted and this was agreed. High officials were invited to sign the Declaration, and, following this and his thanks to all who had attended and made the meeting a success, the meeting was closed.

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Annex 1

VENICE DECLARATION OF THE RHN

English Only

Venice Declaration of the RHN WHO Regions for Health Network Second Regional Ministerial Forum, 15 December, Venice This Venice Declaration complements the RHN Adoption of Principles document adopted at the First Regional Ministerial Forum in Copenhagen. On 15 December 2003, health ministers and other senior politicians representing the WHO Regions for Health Network (RHN) member regions met in Venice to attend the Second RHN Regional Ministerial Forum, as a follow up to the historic First Regional Ministerial Forum which took place on 24 June 2003 in Copenhagen at the WHO Regional Office for Europe. The WHO Regions for Health Network was established to promote health improvement at the regional level within countries and complement WHO’s country work. Today, there is a strong emphasis on developing common health policies through pan-European networks, cooperating on regional health systems and promoting links between regions. This political Declaration expresses the clear and strong commitment of regions throughout Europe and of WHO to work with each other, through implementing the biennial Work Programme 2004–2005. It is also a reaffirmation of the goals outlined in the RHN Adoption of Principles, adopted by health ministers at the First Forum in Copenhagen. We, the Regional Health Ministers representing regions of the WHO Regions for Health Network, note that regions within countries across Europe are becoming an increasingly important power base for decision-making. There is a general trend towards multi-level governance, with greater power sharing between different levels of government resulting in multiple layers of authority across European, national and subnational levels. We fully support the Network’s Work Programme 2004–20051, as confirmed by member regions at the 11th Annual Conference and General Meeting. 1

Annex I provides details to the first eight projects, for which leading regions have been determined.

EUR/04/5045399 page 16

By doing so, we give concrete expression to the basic principles adopted in June – policy, information and quality:

Regions for Health Network Work Programme 2004–2005 — — — — — — — —

Alcohol and Drug Related Harm Prevention Cross-Border Health Tourism Investment for Health Joint Information Project – Mapping Regional Health Indicators (Core Project) Policy Exchange and Development (Core Project) Public Health Strategies for Measles Elimination by 2010 Roma Health Trauma Registry Quality of Health Services * Health Impact Assessment *

— —

* Leading regions to be confirmed

We confirm that regions are an appropriate level for the successful implementation of these projects. We have confidence that the above Work Programme will result in providing important evidence and tools for regions and for WHO. We look forward to sharing the experiences of the Network, which will contribute significantly to efforts toward the universal goal of improving the health and well-being of all citizens. We are committed to providing continual support through the Regions for Health Network, to ensure that health is placed high on political agendas. We expect the WHO Regional Office for Europe and the RHN Secretariat to strongly support the implementation of this Programme and related activities. Finally, we agree that there is a need for permanent annual consultations between WHO and the regional ministerial level. Venice, 15 December 2003.

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Regions for Health Network (RHN) Work Programme 2004–2005 Alcohol and Drug Related Harm Prevention Leading Region: Västra Götalandsregionen This project will develop a set of criteria which should be based on evidence, experience and good practice, by adopting the concept of the WHO Safe Community approach on prevention of alcohol. The Safe Community approach has shown to be effective in reducing accidents. In the same way alcohol and drug harm prevention criteria could be expected to have the same results in reducing alcohol- and drug-related harm. These criteria will be provided to municipalities and if politically committed they will facilitate the adoption of effective intervention strategies against alcohol and drugs. They will also make it easier for decision makers to identify potentially counterproductive policies. Projected Timetable The project will start in January 2004 and end in December 2005, comprised of three phases: a) identification, 2) outline, and data collection and evaluation. Policy, Information, Quality, Child an Adolescent Health Each participating region cover their own costs; hosting regions cover the costs of common arrangements as venues, social arrangements etc. In the first phase participants should (a) identify a common set of criteria for policy and agree on how to approach different local communities and (b) outline a surveillance system. During the second phase the criteria are implemented via agreements with local communities within regions and agreements on how to perform the base line surveys. The third phase comprises data collection and evaluation of the process and outcome. A set of criteria on good quality alcohol and drug preventive policy including guidelines for surveillance/mapping of alcohol/drug abuse. Kaunas, Madeira, South Tyrol, Ticino, Usti, Varna, Vologda

Priority areas involved Resources

Collaboration

Final Products Regions to be committed

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Regions for Health Network (RHN) Work Programme 2004–2005 Cross Border Health Tourism Leading Region: Veneto This project will focus on cross-border patient mobility and other health issues related to tourism. While the emphasis is often on emergency care, there are other issues such as related to with chronic conditions. This project would increase understanding of these issues and share experience, possibly building to provide a stable source of information and support for the EU. Projected Timetable Priority areas involved Resources The project would start May 2004 and be completed by May 2006. Policy and Information Funding expected from the new Public Health Programme 2004 or ERANET Programme. Regions are expected to cover participation related to their Focal Points and travel two times per year to meetings. The first common meeting would set up way of working, which may involve that other regions would provide information on citizens seeking health care abroad demand for medical services in EU and candidate countries, assessing both the health and the economic impact — health services offered and the level of resourcing required — costs of providing services for residents and tourists — various health protection systems in use in the country — —

Collaboration

Final Products Regions to be committed

Guidelines and re-organizations of health services for tourists and bilateral agreements between regions Catalonia, Carinthia, Madeira, North Rhine-Westphalia, Timis, Västra Götalands.

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Regions for Health Network (RHN) Work Programme 2004–2005 Investment for Health Leading Region: North West England The North West launched its Investment for Health Plan in July 2003. It recognizes that action across sectors is required to improve health and reduce inequalities, which in turn produces economic and social benefits, and reduces the demand for health and social care. Integrated action is developing to ensure that all policies and programmes achieve these aims, for four agreed priorities – tackling the wider determinants of health, developing the good “corporate citizen” role of the National Health Service (NHS), reducing inequalities in service delivery, and strengthening primary care services. The “corporate citizen” priority has developed rapidly, with the recognition that health and social care systems are major economic, social, and environmental players. The health system has a vital role in securing wider regeneration, through its recruitment, training, employment, procurement, capital development, and other activities. North West England will collaborate with the Investment for Health Centre in Venice, and a group of regions from inside and outside the network, which have experience of developing this approach and are interested in taking it forward.

Projected Timetable

Priority areas involved Resources Collaboration

Final Products

Regions to be committed

Starting in January 2004, the initial collaboration will define a longer term programme which will include joint work between a group of regions and the Venice Centre, possible participation in EU programmes, such as Interreg IIIC, and a process to share experience within RHN. Policy, information, delivery programmes, capacity building. The North West would be willing to host a meeting of interested regions to define the programme. Resources for joint work, with the Venice Centre, and for EU programmes, will be defined and sought. The work with the Venice Centre would involve regions in: • Identifying concrete examples of how IfH processes and actions have been incorporated into overall development frameworks. • Sharing experience of how partnership working across sectors has contributed to policies and programmes which influence the wider determinants of health, and develop the good ‘corporate citizen’ role of the health sector. • Providing learning and tools which support the application of IfH at the Regional level. • Participating in annual Venice Centre Workshops to shape the application of IfH at the Regional Level. Regions within possible Interreg Projects would be part of a learning network. • Contributions to Venice Centre IfH development products. • Internal development reports. • Common, transferable methodologies and policies. • Technical reports on specific tools which can be jointly used and promoted. The initial phase will establish commitment amongst regions expressing an interest in being involved: Catalonia, Kaunas, Valencia, Västra Götaland, Veneto, Wales, Usti. Other Regions would be free to participate in the initial phase.

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Regions for Health Network (RHN) Work Programme 2004–2005 Joint Information Project – Mapping Regional Health Indicators (Core Project) Leading Region: North Rhine-Westphalia Important preparatory work of a common data set has already been achieved by the Network through the development of a “Common Minimum Indicator Set”, a project led by North RhineWestphalia. This Joint Information Project would result in a geographical information system with an integrated tool for analysis. The “Health for All (HFA) Database,” developed by the WHO Regional Office for Europe, would be used as a base. The regional level had already been included when this software was developed. Regional data which are already available can be integrated into the system. As the HFA database interfaces for data integration have been described, it will be feasible for the regions to integrate their data in a standardised way into this database. If possible, compatibility with the data/indicators of other regional database projects, e.g. ISARE, should be achieved in a project carried out under the European Public Health Programme. Projected Timetable Priority areas involved Resources Development starts at the beginning of 2004 for this long-term project. First discussions for preparation have started. Policy and Information. North Rhine-Westphalia provides concept input. Each region will then have to invest in their own indicator development. A second step would be to approach EU for funding. After project concept is set up, regional data which are already available are to be integrated into the system. At the end of the project, indicators information from about 30 regions in Europe will be available for joint analysis. A report of the results would be made available. The core group for the project concept development consists of: Emilia-Romagna, Kaunas, Madeira, Szabolcs-Szatmar Bereg, and Västra Götaland. As this is a core project, all regions would be requested to take part.

Collaboration Final Product

Regions to be committed

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Regions for Health Network (RHN) Work Programme 2004–2005 Policy Exchange and Development Project (Core Project) Leading Region: Wales If regions are to be able to compare policies and share experience and understanding, easy access to each other’s policies, priorities and plans is essential. Wales has developed an initial example of how a website might summarise major health policies in a region: http://www.wales.gov.uk/subihealth/hscwb/hscwb-page1-e.htm The aim is an RHN standard that all regions could be asked to use to develop web pages. A standard web page format would provide an effective information base on which further analysis of policy development can be based. Projected Timetable Priority areas involved Resources The planned work would be complete by the end of 2004, but the project would continue. Policy, and all areas covered by policy This project will initially require little if any central funding, as the responsibility will rest with the individual regions. However, WHO Regional Office will need to adapt its own web pages to reflect this work and allow fast access to the regional sites. All members have been invited to comment on an initial web site for presenting regional health policy and Wales is leading work with a small group on developing this idea further. Subject to the views of the group and members, the aim might initially be an RHN standard for regional policy web pages. A second phase might include: the development of a model policy framework; the development of model policies for shared priority health areas; — analysis of policies across the RHN; — evaluation of selected policy areas across the RHN. — —

Collaboration

Final Products

Regions to be committed

As this is a core project, all regions would take part.

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Regions for Health Network (RHN) Work Programme 2004–2005 Public Health Strategies for Measles Elimination by 2010 Leading Region: South Tyrol Even with high coverage rates, measles epidemics may occur due to accumulation of susceptibles, underlining the necessity of well functioning surveillance and additional strategies like catch-up campaigns. The vaccine coverage with MMR is likely to differ significantly among the participating RHN regions. Factors which have been shown to significantly influence the vaccine coverage are vaccination schedules (mandatory versus recommended), offer free of charge, organizational aspects like active invitation, etc. This project will collect information on vaccination schedules, and organizational aspects (invitation, incentives, vaccination registries etc.), which will be obtained from partner regions with the aim of creating an inventory of what is currently in place. A case control analysis will depend on the number of regions participating. Coverage rates will be considered as outcome and all other aspects as risk factors. The objective is to identify the most important risk factors for low coverage in order to define recommendations. Projected Timetable The project is planned to start in January 2004. By March 2004 the questionnaire should be sent to all participating regions, and by June a descriptive analysis on measles control should be available. Policy, Quality, Information, Child and Adolescent Health Each region takes over the own expenses related to the project. If a region is hosting a meeting, it takes over the expenses for the organization (not travel, board and lodging expenses of the single participants, except special social events organized by the region). — — — —

Priority areas involved Resources

Collaboration

Establishment of specific working groups in the partner regions; Development of a common agenda; Meetings and exchange by e-mail; Presentation of results at annual RHN meeting.

Final Products

Development of common strategies and guidelines for training, information and education regarding control of measles and training and workshops for health personnel. Regions that have either implemented efficient/successful measles vaccination strategies or regions that are putting in place measles control/elimination measures.

Regions to be committed

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Regions for Health Network (RHN) Work Programme 2004–2005 Roma Health RHN Leading Region: Györ-Moson-Sopron This project on the health of socially vulnerable groups is prompted by a problem that is attracting increasing attention in the Györ-Moson-Sopron region. There is little experience on how to tackle it, and awareness that a new methodology was required. This project would take upon case studies of the Roma people, a population which is relatively undereducated, poor and isolated. The principle aim of this project is to prepare key persons from the Roma population to act as helpers of their community and to participate in solution of local problems. Projected Timetable The Preparation stage will take place from January to April 2004. The second stage of Training will take place from May to September 2004. Policy, Information, Mental Health and Child and Adolescent health. This project will run as a modest programme in Györ-Moson-Sopron county with a minimum amount of money. Additional funding possibility to be considered is to collaborate with other regions in applying for EU funds. Along with providing leadership in the project, Györ-Moson-Sopron can provide technical organisation for the methodology guidebook. Collaboration Final Product Case studies and experiences on helping the Roma populations from other regions are sought. Guidebook with guidelines based on experience and completed with a methodology, including case studies from programs involving Roma population in Hungary and participating RHN regions. Szabolcs-Szatmár-Bereg, Usti and other regions with Roma populations.

Priority areas involved Resources

Regions to be committed

EUR/04/5045399 page 24

Regions for Health Network (RHN) Work Programme 2004–2005 Trauma Registry Leading Region: Kaunas The Trauma Registry is an information system of the most seriously injured patients and the treatment that they have received. The purpose of the registry is to evaluate the quality of trauma patient care and to plan and evaluate injury prevention programs. The criteria (to be discussed) for inclusion in the trauma registry are patients with injuries who are admitted to hospital, held for observation, transferred to another acute care hospital, or declared dead in the emergency department, and for whom contact occurred within 30 days of the injury. Injuries include trauma, poisoning, suffocation, and the effects of reduced temperature. Projected Timetable Priority areas involved Resources 2004–2006, depends on number of regions involved (at least 5) and successful application to the EU Public Health program. Policy, Quality, Information, Environment Kaunas region (Regional Public Health Center, Kaunas University of Medicine, National Health Information Center) will draft the project proposal providing sufficient manpower and necessary finances. Other interested RHN member regions will be requested to provide necessary information and suggestions for application. The project will be implemented following these guidelines: • Evaluation of existing registration forms and accessible information; • Preparation of the unified registration forms; • Preparation of registration forms for use in computerized database; • Design of database and registry network; • Purchasing computer and telecommunication equipment (if needed); • Decision on Criteria for Trauma registry; • Pilot study; • Publishing and implementation of registration forms; • Training of personnel; • Spreading of information (workshops/conferences) – presentation of the Trauma registries for the network and within the regions; • Evaluation of the project. Database: Trauma registry at the regional level as a tool for information, heath policy formulation, continuous quality improvement in related health care sectors. To be confirmed.

Collaboration

Final Products

Regions to be committed

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Venice Declaration signed 15 December 2003 Page 1/2

Armenia Sunik

Austria Carinthia

Bulgaria Varna

Czech Republic, Moravia-Silesia

Czech Republic Usti

Germany North RhineWestphalia

Hungary Györ-MosonSopron

Hungary Szabolcs-Szatmar

Italy South Tyrol

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Venice Declaration signed 15 December 2003 Page 2/2 Italy Veneto

Lithuania Kaunas

Poland Upper Silesia

Portugal Madeira

Romania Timis

Russian Federation Vologda

Sweden Östergötland

United Kingdom North West England

United Kingdom Wales

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Venice Declaration signed after the meeting on 15 December 2003 Page 1/1 Belgium Flemish Community

Italy Tuscany

Spain Catalonia

Spain Valencia

Sweden Västra Götaland

Switzerland Ticino

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Annex 2

FINAL LIST OF PARTICIPANTS RHN MEMBER REGIONS Armenia – Sunik Region Dr Zhasmen Stepanyan* Chief, Sunik Region Department of Public Health Services Care and Social Affairs 5 Toumanian st. Art. 8 377 810 Kapan Austria – Carinthia Dr Peter Ambrozy Vice President Region of Carinthia Amt der Kärntner Landesregierung Arnulfplatz 2 A-9020 Klagenfurt Dr Hugo Tschernutter* Head, Social Policy and Health Legislation Regional Government of Carinthia Amt der Kärntner Landesregierung Arnulfplatz 2 A-9020 Klagenfurt Dr Petra Oberrauner ECC Euralp Crossborder Consulting Moritschstrasse 2/2 9500 Villach Mr Gerald Passegger Amt der Kärnter Landesregierung Arnulfplatz 2 9020 Klagenfurt Mrs Claudia Roseano Amt der Kärnter Landesregierung Arnulfplatz 2 9020 Klagenfurt

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Bulgaria – Varna Dr Zdravko Markov Regional Minister of Health Municipality of Varna Varna Regional Health Directorate 43 Osmi Primorski polk st. 9002 Varna Professor Stoyanka Popova* Dean Medical University of Varna Faculty of Public Health Marin Drinov str 55 9002 Varna Czech Republic – Moravia-Silesia Mr Jirí Carbol Deputy Regional President Moravian-Silesian Regional Authority 28. ríjna 117 70218 Ostrava Dr Jaroslav Volf* National Institute of Public Health Srobarova 48 10042 Prague 10 Mrs Dagmar Adamova Head, Health and Social Committee Moravian-Silesian Regional Authority 28 rijna 117 70218 Ostrava 2 Dr Helena Sebakova Regional Public Health Authority Northern Moravia Regional - Ostrava Na Belidle 7 70200 Moravska Ostrava Czech Republic – Usti Region Mr Vladimir Zahorsky Regional Minister of Health Usti Region Husova 422 440 01 Podborany

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Dr Josef Richter* Regional Institute of Public Health Moskevska 15 400 01 Usti nad Labem Dr Stanislava Richterova Director Regional Institute of Public Health Moskevska 15 400 01 Usti Nad Lasem Mrs Martina Skvarova Regional Institute of Public Health Moskevska 15 400 01 Usti nad Labem Mr Miroslav Strachal Finance Director Regional Institute of Public Health Moskevska 15 400 01 Usti nad Labem Germany – North Rhine-Westphalia Mrs Cornelia Prüfer-Storcks State Secretary Ministry of Health, Social Affairs, Women and Family North Rhine-Westphalia Fürstenwall 25 40219 Düsseldorf Dr Birgit Weihrauch* Ltd. Ministerialrätin Ministry of Health, Social Affairs, Women and Family North Rhine-Westphalia Fürstenwall 25 40219 Düsseldorf Hungary – Györ-Moson-Sopron Mr Matyas Firtl Deputy President General Assembly of the County of Györ-Moson-Sopron Arpad ut. 32 9021 Györ

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Dr Erzsebet Bazsika* Head of Health Promotion Department Public Health Institute (ANTSZ) Györ-Moson-Sopron County Josika u. 16 9024 Gyor Hungary – Szabolcs-Szatmar Bereg Dr Gabor Kiss Deputy President of the General Assembly Szabolcs-Szatmar-Bereg County Hösök tere 5 4400 Nyiregyhaza Dr Marianna Penzes* Public Health Office Arok ut. 41 H-4400 Nyiregyhaza Ms Bella Balazsy Autonomous Government of Szabolcs-Szatmar-Bereg County Hösök tere 5 4400 Nyiregyhaza Italy – Emilia-Romagna Dr Marco Biocca Agenzia Sanitaria Regionale dell’Emilia-Romagna Regional Health Agency of Emilia-Romagna Via Aldo Moro 21 40127 Bologna Italy – Sicily Dr Pina Frazzica* Director General Centre for Training and Research in Public Health – CEFPAS Via G. Mulè, 1 I-93100 Caltanissetta Italy – South Tyrol Dr Otto Saurer Minister South Tyrol Ministry for Health and Social Affairs of the Autonomous Province of South Tyrol Freiheitsstrasse 23 I-39100 Bolzano

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Dr Giulia Morosetti* Director Health Department 23 Autonomous Province South Tyrol Corso Libertà 23 I-39100 Bolzano Italy – Veneto Dr Fabio Gava Vice President of the Veneto Region Regional Minister of Health Veneto Region Palazzo Balbi Dorsoduro 3901 I-30125 Venice Dr Franco Toniolo General Director for Health and Department of Health Veneto Region Social Services Palazzo Molin San Polo 2513 I-30125 Venice Dr Luigi Bertinato* Director Office for International Public Health and Social Programmes Department of Health Veneto Region Campo Santa Marina, Castello 6074 I-30122 Venice Lithuania – Kaunas region Dr Henrikas Ceida Regional Minister of Health Governors Administration of Kaunas County L. Sapiegos 10 LT-3000 Kaunas Professor Zilvinas Padaiga* Prorector Kaunas University of Medicine A. Mickeviciaus str. 9 LT-3000 Kaunas

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Poland – Upper Silesia Mrs Malgorzata Ocheduszko Ludwig Vice Chairman of Regional Parliament Silesian Seym Sejmik Wojewodztwa Slaskiego Ligonia 46 40037 Katowice Dr Jacek Czapla* Director Department of Social Policy Silesian Voivodship Office ul. Powstancow 41a PL-40024 Katowice Portugal – Madeira Dr Conceição Estudante Regional Secretary Social Affairs Rua das Hortas 30 9050-024 Funchal Portugal Dr Miguel Stringer Pestana Coordinator Regional Office for Social Affairs Rua das Hortas no. 30 P-9050-024 Funchal, Madeira Portugal Romania – Timis Region Mr Constantin Ostaficiuc Vice President Timis county 17 Revolutiei Bvd 1900 Timisoara Dr Dana Paica* Timis County Council Bdl. Revoluties 1989 Nr. 17 1900 Timisoara

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Russian Federation – Vologda Dr Alexander A. Kolinko* Head Public Health Management of the Vologda Administration 2, Hertzen Str. 160035 Vologda Spain – Catalonia Dr Ricard Tresserras* General Direction of Public Health Pavello Ave Maria Department of Health and Social Security Public Health Division Travessera de les Corts 131-159 E-08028 Barcelona Spain – Valencia Dr Carmen Sanchis Piñol* Head Valencia School of Health Studies International Programmes C/ Juan de Garay 21 E-46017 Valencia Sweden – Östergötland Mrs Agneta Niklasson Regional Minister The County Council of Östergötland St. Larsgatan 49B S-581 91 Linköping Dr Birgitta Larsson* Project Manager County Council of Östergötland St Larsgatan 49B S-581 91 Linköping Sweden – Västra Götaland Dr Göran Henriksson* Senior Public Health Adviser Folkhälsokommitténs Kansli, Regionens hus Västra Götaland Region S-54 287 Mariestad

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Switzerland – Ticino Professor Gianfranco Domenighetti* Head Departamento delle opere sociali Sezione sanitaria (DOS) Via Orico 5 CH-6500 Bellinzona United Kingdom – North West England Mr Dave Quayle Councillor North West Regional Assembly Wigan Investment Centre, Waterside Drive Wigan WN3 5BA Mr Peter Flynn* Deputy Regional Director, Public Health North West Public Health Team Government Office for the North West Department of Health Directorate of Health and Social Care Room1816, Sunley Tower, Piccadilly Plaza Manchester M1 4BE United Kingdom – Wales Ms Jane Hutt Minister of Health and Social Services National Assembly for Wales Cathays Park GB-Cardiff CF99 1NA Mrs Ann Lloyd Director, Health and Social Care NHSD Welsh Assembly Government Cathays Park GB-Cardiff CF99 1NA Mrs Margaret Davies National Assembly for Wales Cathays Park GB-Cardiff CF99 1NA

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OBSERVER REGIONS Italy – Campania Region Mrs Rosalba Tufano Italy – Tuscany Region Giorgio Almansi Region of Tuscany Department of Right to Health Via di Novoli, 26 I-50100, Florence Mrs Maria Jose Caldes “A. MEYER” Children’s University Hospital Via Pico della Mirandola 24 50133 Florence Mrs Katalin Majer “A. MEYER” Children’s University Hospital Via Pico della Mirandola 24 50133 Florence Maria José Caldés Pinilla “A. MEYER” Children’s University Hospital Via Pico della Mirandola 24 I-50133, Florence Mr Fabrizio Simonelli “A. MEYER” Children’s University Hospital Via Pico della Mirandola 24 50133 Florence Mrs Donatella Tanini Region of Tuscany Department of Right to Health Via di Novoli, 26 I-50100, Florence Lithuania – Panevezys Region Dr Raimonda Ulianskiene Panevezys County Governor's Administration Respublikos 38 LT-5300 Panevezys

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Russian Federation – Chuvasia Region Mrs Nina Suslonova Regional Minister of Health Republic of Chuvashia Uritzky str. 43 Cheboksary 428004 Mrs Natalia Belova Director, Health Insurance Foundation c/o Ministry of Health Chuvash Republic Uritzky str. 43 Cheboksary 428004 Dr Mary Collins, WHO Health Care Policy Adviser WHO Office for the Russian Federation 28 Ostozhenka Street 119034 Moscow Professor Serguei Volkov Project Interpreter Moskovsky prospect 45 Cheboksary 428017, Chuvashia SPEAKERS Dr Josep Figueras Head, European Centre for Health Policy c/o Service public fédéral (SPF) Santé publique, Sécurité de la Chaîne alimentaire et Environnement Montagne de l'Oratoire 20, boîte 3 B-1010 Brussels Belgium Professor Klaus Hurrelmann Director Faculty of Public Health University of Bielefeld WHO Collaborating Center for Child and Adolescent Health Promotion PF 100 131 D-33501 Bielefeld Germany

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Dr Erio Ziglio Head WHO European Office for Investment for Health and Development Campo Santa Marina, Castello 6073 I-30122 Venice Italy REPRESENTATIVE FROM THE EUROPEAN COMMISSION Mr Dario Zanon Detached National Expert EuropeAid Co-operation Office European Commission Rue de la Loi/Weststraat 41 1040 Brussels Belgium HOST REGION Brussels office Mrs Mariantonietta Fresu Mrs Eleonora Martinello Mr Francesco Ronfini Veneto Region – Brussels Office Rue de l’Industrie 22 1040 Brussels Belgium RAPPORTEUR Dr Christopher Riley United Kingdom WORLD HEALTH ORGANIZATION Regional Office for Europe Mrs Albena Arnaudova, Communication Officer Dr Roberto Bertollini, Director, Division of Technical Support – Health Determinants Dr Marc Danzon, Regional Director Mrs Birthe Havn, Programme Assistant, Regions for Health Network Mrs Wendy Tse Yared, Coordinator for the Regions for Health Network * = Focal Point for the Regions for Health Network



WHO Regions for Health Network Second Regional Ministerial Forum

Venice, Italy, 15 December 2003

English only

ABSTRACT

The importance of regions in health development is increasingly being recognized in Europe. As regions are close to their populations, have a close understanding of local health problems, and have the capacity to allocate resources for action, the regional level is ideal for health policy development. Regions in many countries already have considerable responsibilities for health and health care, while others are acquiring them through the process of devolution. The Regions for Health Network (RHN) of the World Health Organization, recognizing these developments and their importance for health improvement, organized the Second Regional Ministerial Forum in Venice to take advantage of the momentum generated by the first held in Copenhagen in June.

High-level representatives heard and commented on background presentations on the new WHO European Office for Investment for Health and Development, health systems decentralization in Europe, and health information and regional cooperation. It was followed by a round table discussion on important issues for the future of the Network, after which ministerial representatives agreed to sign the Venice Declaration that set out the RHN’s work programme for the biennium 2004–2005.

Keywords REGIONAL HEALTH PLANNING HEALTH POLICY HEALTH PROMOTION DELIVERY OF HEALTH CARE – trends INTERNATIONAL COOPERATION CONGRESSES EUROPE

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© World Health Organization 2004

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The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Where the designation “country or area” appears in the headings of tables, it covers countries, territories, cities, or areas. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement.

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CONTENTS

Page

Opening session............................................................................................................................1

Welcome by the Minister of Health for Veneto Region..................................................................1

Welcome by the Regional Director of the WHO European Region ...............................................2

Greetings from the European Commission ...................................................................................3

Presentations ................................................................................................................................4

Regions and the WHO European Office for Investment for Health and Development.........4

Health systems decentralization – The role (and challenges) for the regions......................5

Health information and regional cooperation – experience of the Health Behaviour of School-Aged Children (HBSC).........................................................................................7

The round table discussion ...........................................................................................................9

Introduction ..........................................................................................................................9

Contributions......................................................................................................................11

Response by the Regional Director of the WHO European Region............................................14

Adoption and signing of the Declaration and Conclusion............................................................14

Annex 1. Venice Declaration of the RHN ....................................................................................15

Annex 2. Final list of participants.................................................................................................28

EUR/04/5045399 page 1

Opening session

The meeting was opened by Mrs Wendy Tse Yared, Coordinator of the Regions for Health Network. The participants elected Dr Marc Danzon, the Regional Director of World Health Organization (WHO), Regional Office for Europe and Dr Fabio Gava, the Minister of Health of the Veneto Region as joint Chairpersons, and Dr Chris Riley from the United Kingdom as Rapporteur. The agenda and programme of the Forum were adopted. Dr Gava provided the official welcome. Mrs Wendy Tse Yared welcomed the political representatives from 28 regions across Europe. This meeting would continue the momentum started in June at the First Regional Ministerial Forum, where basic principles were agreed on areas of joint working. A main item for the round table discussion later in the session would be the proposed work programme for the two years 2004–2005 based on these principles. The work programme had been approved during the Network’s Annual General Meeting in Teplice in the Czech Republic in November. Member regions had then agreed to focus on activities that would help define good regional health policy, generate evidence and tools, and provide new knowledge to support the common goal of the regions and WHO – to improve the health of Europe’s citizens. On behalf of the Network, she thanked the Regional Director for his support in attending the meeting, the Veneto Region for their generosity and hospitality and the Veneto focal point, Dr Luigi Bertinato, for organizing what would be an important forum.

Welcome by the Minister of Health for Veneto Region

Dr Danzon took the Chair and introduced Dr Fabio Gava, Regional Minister of Health of the Veneto Region one of the hosting partners for the WHO European Office for Investment for Health and Development. Dr Gava recalled that a year prior to this event in Palermo in Sicily, regional ministers had assembled for the first time to celebrate the 10th anniversary of the Regions for Health Network (RHN). He was delighted that so many were able to attend this meeting in Venice. The Palermo meeting was followed by the First Regional Ministerial Forum held in Copenhagen, hosted by Dr Danzon at the WHO Regional Office for Europe. Dr Gava welcomed Dr Danzon and his colleagues from the WHO to Venice as well as ministers and officials from regions across Europe. Issues such as cross-border health and the free movement of patients and health professionals were raised in Palermo and again considered during the Italian Presidency in the second half of 2003 as suggested by the Italian regions. Health issues in an enlarged Europe were defined as being important not only for countries, but also for regions, considering that the RHN regions present at the Ministerial Conference in Venice represented some 80 million people from across Europe. Health issues underlay differences in the social development and social security system of Europe, and these had gained in importance now that the concept of an enlarged Europe was becoming ever more consolidated. Rapid economic development had caused difficulties, especially in some of the countries that had previously been outside the European Union that were now joining, the reason

EUR/04/5045399 page 2 being they were now receiving collaboration. WHO recognized the strong links between social and economic development, and this was the reason that the Network needed to encourage Regions to share their ideas, and give the European Union the benefit of their views and experience. The enlargement of the European Union will also have long-term effects on human health due to the high level of inequalities in health services provision and access, especially in those services provided directly by the Regions. A further point of discussion related to the appropriate way of dealing with health care. The Venice Ministerial Conference will be of vital importance to set up a forum for debate where Ministers regularly have the opportunity to meet and discuss about European political health issues. Debates involving the regions could help make more informed decisions within the European Union and in European Institutions. The Veneto Region congratulated Dr Danzon on his and WHO’s support for organizing this event. The future working programme of the RHN would be discussed at length among the 24 delegations attending the meeting. During this meeting, a number of projects to be developed in collaboration between the Regions of the Network would be presented, including the Investment for Health strategies. This meeting offers an occasion to discuss the opportunity to work in close collaboration with the European Observatory on Health Care Systems with the aim of developing a comparative study on the decentralization of health care systems in Europe. Dr Gava concluded by thanking again all those present for attending and contributing.

Welcome by the Regional Director of the WHO European Region

Dr Danzon expressed his pleasure at seeing so many regions present – more than in Copenhagen in June. It was important to have such meetings, not too often perhaps, but certainly regularly. A network should meet and exchange views. The view is gaining ground that the region is the right size for many functions, so it is a good time for the Network to become stronger. But it must also be clear. WHO’s constitutional relationship is with ministers of health at the national level. That must not change, but as Dr Gava said it is good for countries to have strong and well functioning regions. Countries will come to appreciate the benefits of having a network of strong regions supporting health improvement. In Copenhagen, Dr Danzon had issued a challenge to the Network, and he did so again. Two points were proposed for the agenda. The first was to make clear the role of regions in relations to health policy, health systems and health professionals – what can and should be done, and how? These issues are on the national agenda, and should also be on regional agenda. There needed to be transparency and guidelines on who would do what. The second was for all parties to draw together knowledge on public health issues, and make it known wherever it might be useful.

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Through working on these two issues, the Network could be truly beneficial to those beyond its membership. The proposals were noted in the work programme:

• alcohol and drugs – a topic of worldwide concern and high on the Agenda of the WHO Regional Office for Europe;

• cross-border issues – a cause of concern for many countries;

• Investment for Health – an obvious issue for the meeting in Venice;

• regional indicators – essential when information is so often lacking, and especially important when more local sources offer better quality and relevance;

• policy development – also essential for the Network;

• Roma health – a good example of equity and solidarity;

• quality – this was especially noted, as perhaps the future prime focus for WHO – to ensure that more is achieved from the limited resources available;

• health impact assessment – also a major theme. All were crucial. Enlargement would be vital to all 25 of the European Union countries – and to their regions. The issue of mobility would also be vital to them all. A regional network could therefore perhaps usefully work closely with the EU. But he also noted that many of the countries in the WHO European Region would still be outside the EU, and WHO must work with all. These too would need strong support, and he urged the Network to help them.

Greetings from the European Commission

Dr Gava then introduced Dr Zanon, who was speaking as a national expert from the Veneto Region and tendered the apologies of Bernard Merkel and Tapani Piha of the European Commission, who were unable to attend. On their behalf, Dr Zanon offered greetings and support from the European Commission and passed on the regret of Mr Fernand Sauer, the Director for Public Health in the Directorate General for Health and Consumer Protection at the European Commission, that he could not attend the meeting, which would address some of the most important health policy issues facing Europe. Regions are increasingly important in the area of health care and the Commission had supported several projects under the public health programme that addressed their role in health. These had provided information about the similarities and differences between regions and highlighted the possibilities for future action. One example was the EVA project, which had found great heterogeneity among published regional and national public health reports. The project team had concluded that development of common methods for preparing reports would increase the attention the reports attracted, and improve their usefulness in the policy-making process. The Commission, believing that sharing experience and knowledge will benefit all involved, offered full support to the collaboration between the regions in the Network and looked forward to working with it. It was also expressed that Commission representatives could participate in future meetings.

EUR/04/5045399 page 4 Presentations

Three presentations were made on important background issues relating to the work of the Network.

Regions and the WHO European Office for Investment for Health and Development

Dr Erio Ziglio, the Head of the WHO European Office for Investment for Health and Development, presented this topic as the link between the work of the RHN and the work of his new Office opened that morning. Regions are clearly acquiring a greater role in planning and administration. Both regions and the Venice Centre are interested in linking health and social development, and therefore there is a very good basis for joint action. The inclusion in the work programme of a project on Investment in Health was not a surprise as that was already the title of the health policy of North West England, the region that would be leading the project. The Venice Office is very interested in pragmatic collaboration, and would want to encourage case studies; help develop and provide methods, tools and know-how to support action to improve health; and organize learning opportunities and training for health managers and regional decision makers. Dr Danzon queried the type of case studies the Venice Office might undertake with regions as against those at national level. Dr Ziglio cited the example that North West England is aiming to reduce health inequalities and said that the Centre could help analyse their activities and results. Another possibility would be to work with say five or six regions and compare how they were trying to raise the importance of health inequalities in overall policy-making. Dr Danzon wondered whether it might be possible for the Centre to follow up its publication on action through health systems to tackle poverty, for example by improving access, with a second on action at the regional level. Dr Ziglio reflected that it would be very useful to do so – to complement information already available at the national and the local level. North West England added that much had been done in the region to improve health. The main determinants of poor health were economic, social and cultural and the region was aiming to tackle these through action on housing, jobs and the general economy; through health and social care; and through using its economic influence as a major employer. Dr Ziglio said that other regions were also interested in such action, and the power of regions as employing and purchasing organizations needed to be explored more fully. There was a general understanding that health and economic factors were linked – the issue now was to identify more clearly what needed to be done. He wanted to collect and analyse some concrete examples. Dr Ziglio reiterated that the Venice Office is indeed ready to work on the project proposed by North West England and with the involvement of a few more very committed regions. The project is seen by the Venice Office to have very clear outcomes and products which include: analysis of Investment for Health tools and methodologies, know-how transfer and development; and the development of a training and skill development package that could be used to disseminate the learning from the project throughout Europe. Wales supported that targeting poor health was a strong policy aim and said it would be very important for the Centre to act as a channel for sharing learning and outcomes. Wales had

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reformed the funding allocation process to target the areas with the worst health and was looking for measurable health gain especially in relation to heart disease.

Health systems decentralization – The role (and challenges) for the regions

Dr Josep Figueras, Head of the European Observatory on Health Care Systems and Policies at the WHO Regional Office for Europe, presented the work of his office as one centred on gathering evidence for effective action in the health field. He felt particularly pleased and privileged to be making his presentation in Venice, as the Veneto region had always been a great help to and a strong collaborator for the Observatory. Four issues were addressed.

• What did decentralization mean? It was more than just a trend involving regions.

• What issues did regions face?

• The issue of stewardship as a common thread linking the changes.

• The potential role of evidence and of the Observatory. Decentralization is not a single simple process but can take a number of forms, and four different types were used. The first was “deconcentration” – the transfer of administrative tasks and functions to a lower tier – to regions, counties, provinces and municipalities. This might in some circumstances be interpreted as a form of centralization of power if it served to give the higher level more control over the lower. The second was political devolution, passing authority down to the lower level. The third was delegation of tasks, which might for instance be passed out to social health insurance bodies or to professional regulators. The fourth was privatization, which could be to profit-making or not-for-profit bodies. Within health systems the decentralizing tendency is evident, in a number of ways. One is a shift in the balance of roles between the state and the market, provoking a need to develop the stewardship role of the state. Another is the development of social health insurance systems in the countries of eastern and central Europe and the former Soviet Union. Political devolution is strengthening the regional and municipal levels. Different approaches to the purchaser/provider split have led to the development of strategic purchasing, selective contracting and activity-based payment systems for providers. Provider decentralization has taken the form of self-governing hospitals, public trusts and foundation hospitals, the latter a case of an idea from the United Kingdom being adopted by Spain and then re-adopted in its new form back into the United Kingdom. Another development is the increased role of the private sector, e.g. the increase in private primary care and dental practitioners. A linked process is the growth of patient empowerment. This can take the form of a stronger voice – as through representation or the patient rights movement; a strengthened right of “exit”, with increased choice over which provider to use; and mobility of both patients and service providers within the European Union. Countries and regions face considerable challenges, such as avoiding duplication, fragmentation and poor coordination; keeping down transaction costs and achieving economies of scale; maintaining parity of quality, in the face perhaps of substantial volume variations; ensuring equity of access and coverage; enforcing accountability; and providing adequate local capacity.

EUR/04/5045399 page 6 Movement of control up a tier had also been happening. In Sweden, some counties had been merged in what was effectively a form of centralization. In Germany, efforts to contain costs had led to greater government control of social health insurance bodies, and in Hungary, these had been returned to government ownership. In Estonia, Hungary and Poland regional funds had been merged. The decisions of the European Court of Justice on patient and service mobility could be seen as a form of centralization of decision-making to the European Union level, taking power from both regions and the state. So there is not a one-way process; both decentralizing and recentralizing tendencies are visible. Indeed Norway had seen both, as its hospital decentralization had subsequently been reversed. Regions clearly represent an important element of decentralization, but they are not uniform. There is great diversity in size, models, powers and tasks. Their competence might or might not include planning, funding (collection and pooling), purchasing and provision. The situation depends on decisions outside their own control. Their role must fit into the overall structure and working of the state, and is essentially a political decision. An important criterion must be to ensure that their functions are coherent, and, of course, further changes can always destabilize the situation and create incompatible functions. In this situation Dr Figueras again raised a question he had posed the Network in a previous meeting – with the diminution of the powers of the nation state, were regions the new “stewards”? In other words, would they take on the role of ensuring that the many elements within the health system work in concert and take responsibility for instance for:

• policy leadership

• regulation; and

• managing information and intelligence about health issues?

Without good stewardship, performance would deteriorate. If the national level gave up responsibility for “vertical” stewardship, there would be a need to develop “horizontal” interregional or shared stewardship. So there will be a need for regional health policy leadership. Evidence suggests that that top- down health policy development is insufficient, and that there is a role for regional health policy and planning. There are many regional health targets, for example in Swedish counties, German Länder, Spanish autonomous regions, and French regions. Important public health functions can also be exercised at that level, including health needs assessment. In terms of interregional or shared regulation, there will be a need to clarify the management of central regulatory functions, such as regarding new drugs and training standards; establishing a financial redistribution formula; creating a standardized basic benefit package; accreditation of providers; and regulating and managing patient mobility at the regional, national and European Union level, linked to the provision of centres of excellence. Regarding intelligence and steering the system by means of information, issues to be tackled include providing technical support for information development, benchmarking and standardization of databases and indicators; identification and diffusion of innovations; learning from “natural experiments” and redistributing knowledge from rich to poor regions.

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Making all this happen requires the creation of interregional stewardship mechanisms such as an interregional agency to share responsibility and evidence; accepting that development must be incremental; and creating capacity, credibility and transparency in the system. There would need to be cross-regional transfer of the essential know-how and genuine interregional collaboration. This would not be easy, but would be necessary. He turned to what the Observatory could do to help. One possibility would be to produce regional profiles, perhaps something similar to the “Health Systems in Transition” (HiT) profiles currently produced for each separate country in the European Region. The HiTs included a country overview, and analysis of organizational structure, finance and expenditure, health care delivery, financial allocation system and reform processes. The Observatory had also produced analytical studies in areas such as regulating entrepreneurial behaviour, the appropriate role of the hospital, options for the funding health care, purchasing for health gain, putting primary care in the driver’s seat, human resources for health, mental health and pharmaceuticals. A new set of studies on decentralization in health care would be considering both strategies and outcomes, and would aim to map decentralization strategies, evaluate their impact across a range of societal objectives, assess implementation processes and explore options for policy-makers.

Health information and regional cooperation – experience of the Health Behaviour of School-Aged Children (HBSC)

Professor Klaus Hurrelmann from the School of Public Health in Bielefeld, North Rhine Westphalia, Germany, said that, as a developmental psychologist and social scientist with an interest in child health development, he had observed that young people’s health had in recent years been moving in a new and dangerous direction. He urged his audience to take two steps. The first is to take children’s health seriously – urgent action is needed to avoid a health catastrophe. The second is to establish and use an information and monitoring system, so that they can understand trends and support effective action. Health Behaviour of School-Aged Children (HBSC), a cross-national research study conducted in collaboration with the WHO Regional Office for Europe, is an example of what could be done. It is a study based on a self-reporting system and has been in use for 20 years, providing data of considerable epidemiological importance. It can support monitoring, benchmarking and health improvement and is a valuable source of evidence on health inequalities. Lifelong inequalities start at a very early age. The study aims to gain new insight into, and increase understanding of young people’s health and well-being and health behaviours and of their social context. In addition, the findings from the HBSC surveys are used to inform and influence health promotion and health education policy and practice at national and international levels. Research into children’s health and health behaviour and the factors that influence them is essential for the development of effective health education and health promotion policy, programmes and practice targeted at young people. It is important that young people’s health is considered in its broadest sense, encompassing physical, social and emotional well-being.

EUR/04/5045399 page 8 Health should be viewed as a resource for everyday living, and not just the absence of disease. Research into children’s health therefore needs to consider positive aspects of health, as well as risk factors for future ill health and disease. Family, school and peer settings and relationships need to be explored, as does the socioeconomic environment in which young people grow up, if patterns of health and health behaviour are to be fully understood. The main finding from the data collected is that health status is related to behaviour and behaviour to lifestyle. It is evident that behaving in a healthy way is not fashionable – especially among poor children. Professor Hurrelmann picked out four issues.

• Children have become inactive and exercise rates are low. Children no longer come to grips with their social and physical environment.

• Dangerous nutrition patterns have emerged, quite unsuitable for developing bodies. Fast foods are the fashion, and peer pressure reinforces this. Being overweight is becoming more common; in Germany among some groups 15% of children are obese. The problem is especially common in the less favoured social classes.

• Young people no longer have adequate coping strategies. They cannot deal with frustration and poor environments. Smoking has emerged as a coping approach, and after falling for ten years alcohol consumption is on the rise.

• Childhood has been compressed. Puberty is occurring earlier, down from the age of sixteen and a half years in the 18th century to eleven and a half now and still falling. Children are thus more emotionally challenged and face developmental arousal at an earlier age.

Lifestyle is related to the social situation, as are health inequalities. The result is even lower activity, poorer nutrition, and more smoking, obesity and illness, and increased use of health services. Social inequality among children is very important. Society must respond through health promotion, education and policy action. Unfortunately the “prevention programme dilemma” means that most programmes don’t reach the most deprived groups, who manage to isolate themselves from them. This underscores the vital need for a sound survey approach in every region. HBSC provides intercountry and interregional comparisons, offering an insight into health status, behaviour, lifestyle and context. The target population of the HBSC study is young people attending school, aged 11, 13 and 15- years-old. These age groups represent a period covering the onset of adolescence, the challenge of physical and emotional changes, and the middle years when important life and career decisions are beginning to be made. HBSC is a school-based survey with data collected through anonymous, standardized self- completion questionnaires administered in the classroom. Fieldwork for each cross-national survey is carried out over a period of around seven to eight months, from October to May of the following year. This reflects the sampling strategy used in each country in order to achieve the mean ages of 11.5, 13.5 and 15.5. The HBSC survey instrument is a standard questionnaire developed by the international research network and used by all participating countries. Each survey questionnaire contains a core set of questions looking at the following:

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• background factors: demographics and maturation, social background (family structure, socioeconomic status);

• individual and social resources: body image, family support, peers, school environment;

• health behaviours: physical activity, eating and dieting, smoking, alcohol use, cannabis use, sexual behaviour, violence and bullying, injuries;

• health outcomes: symptoms, life satisfaction, self-reported health, body mass index. Many countries also include additional items in their national questionnaire that are of particular interest on a national level. Dr Danzon asked for examples of how children now are different from those of the 1950s. Professor Hurrelmann replied that a major change is the huge reduction in childhood illnesses. Unfortunately, this good news is offset by an increase in immune deficiency problems. Immune systems seem to have become weaker, and there are unresolved links to eating disorders, inactivity and a failure to develop a strong mind and body.

The round table discussion

Introduction

Dr Gava took the chair for the second part of the meeting, which would lead into the round table discussion. He first invited Mrs Cornelia Prüfer-Storcks, the Secretary of State for Health, Social Affairs, Women and Family of the State of North Rhine Westphalia, to speak. Mrs Prüfer-Storcks thanked Dr Danzon on behalf of the Regions for his attendance at the meeting and thanked Minister Gava for his superb hospitality. It was a very happy coincidence that the meeting should take place alongside the opening of the Venice Office. The intention of those present was to link clearly the strategy of the RHN to the future development of the European Union, and this represented a major opportunity for both. From her region’s point of view the Network offered great potential:

• to support regions in tackling challenges at the European level;

• to encourage learning and development within the regions through knowledge transfer and benchmarking; and

• to contribute to the development of the regional dimension in Europe. She introduced the four items on the agenda for the round table discussion:

• enlargement of the European Union

• mobility of patients

• the role of regions in Europe and the European Union

• the future role and work programme of the RHN. Enlargement of the European Union will have a huge impact. As a result there will be 15 members instead of 25, there will be 20 official languages instead of 11, and the total

EUR/04/5045399 page 10 population will rise from around 375 to around 480 million. New borders and new border regions will be established, and health policy will face new challenges both within and outsides the European Union. There will be repercussions for all, and sharp challenges that regions across Europe and the Network in particular will have to face. One result will be the existence of real and important gaps between the old and new countries in health status, health risks and health care. Life expectancy will vary by up to seven years, and there will be marked differences in infant mortality. The distribution of risk factors such as smoking rates, diet, and alcohol consumption will differ considerably. And the social situation is continuing to change everywhere. There will be worrying gaps in health resources and expenditure – with health-related expenditure accounting for 4.5% of gross national product among the new members of the European Union as compared to 8.6% among the existing members. Many countries are trying to increase the percentage but cannot assume that more resources will increase quality. As a consequence all must try to share knowledge. Network members can improve and enhance services and so improve health. However, not all differences should be abolished. Coming together should be the result of definite decisions, not just through following others. Standardization of health services could cause a problem in Germany if the European Union tried to make everyone the same, through running up against the question of sovereignty. Patient mobility has only recently attracted attention in discussions at the European Union level and between European Union member states, as the European Union has in the past primarily dealt with questions of health protection and problem prevention. It is mainly the rulings of the European Court of Justice that have caused the change. The fact is that patient mobility has increased with tourism, in border regions, through more people spending longer stays abroad and because specific services or services at lower cost or with less delay are available in another country. The result is greater competition, and that is good as it provides the opportunity to learn from good – and bad – practice elsewhere. This also prompts the need for better information, especially to provide greater transparency about services and their quality for patients who travel across borders for treatment. So comparable data becomes essential. In addition, administrative cooperation will have to improve, and the Network will need to pay attention to discussions at government level within the European Union on this issue. Regional cooperation makes a lot of sense and can lead to concrete improvements. The role of regions in Europe and the European Union will continue to develop. The German Länder have long had specific significant responsibilities in the field of health and in other countries too decentralization has increased. Within the new Europe, arrangements are needed that can be easily used and understood by citizens, and it is already at the regional level in many countries that health policy is shaped and implemented and directly experienced by patients. Moreover, experience already shows that regions can often be more flexible and innovative than the national level. The creation of the Network 11 years before had been a cutting edge development, and cooperation at the regional level will remain of central importance for the European integration process.

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The final topic was the Network’s future role and work programme. The new work programme would be the basis for intensified cooperation within the Network and met the commitments made in Copenhagen. It also offered a basis for close cooperation with the European Union and its programmes. The project that North Rhine Westphalia had undertaken to lead would provide a new information base for the Network in close collaboration with both WHO and the EU. Comparable information would be essential for rational cooperation, for the exchange of experience and for learning from each other. Another proposal related to an earlier project – BEN, which had aimed to getter a better insight into regional health information systems and their management and processes. A bid for funding for a follow up project – BEN2 – had been made to the European Union to look at breast cancer and diabetes. The regions were invited to join this project. In concluding, Mrs Prüfer-Storcks stressed to Dr Danzon that the commitments made in Copenhagen could only be fulfilled if the WHO Secretariat were equipped with the necessary means to serve as a reliable partner and supporter of the Regions, and that it would need to be strengthened in terms of resources.

Contributions

Dr Gava then invited others to speak. North West England spoke in relation to two issues – Investment in Health, one of the topics in the work programme, and the role of regions. The main determinants of poor health were not medically related – though obviously health services can do a great deal to alleviate health problems – but economic, social and cultural. That region had been a cradle of the industrial revolution and the factory system, and the decline of heavy industry had left a legacy of poverty and poor health. There was a 10 year difference between the life expectancy in the cities and affluent areas. The point made earlier about a three-point strategy was re-emphasized. Health and social care professionals need to recognize the importance of social and economic determinants of health, and work together and with other agencies to cut health inequalities. Communities need support to secure work, homes and security. Regions need to use their economic power as employers and purchasers. They must intensify their efforts to help hard to reach groups, ensure services support families and make jobs available wherever possible. Dr Gava then contributed to the discussion on behalf of his own region, Veneto. His region attached great importance to the opening of the Venice Office, as it had such an important role. It would be looking at the determinants of health, why some people are marginalized in relation to their health and – most important – what could be done about this. This would be extremely useful to governments. All were increasing spending on health, as the public value health and have rising expectations. By contributing to help improve health through better understanding, the Venice Centre would have a hugely significant role. The second point related to the Network and the Declaration that all were to sign at the meeting. This would cement the relationship between the regions and the WHO, and assist the members in exchanging views. Furthermore, since the Network contained members from both within and outside the European Union, it would give a better insight into what is happening across Europe and help feed back into European Union decision-making more generally. The WHO link represented a dimension that could support developments that otherwise might not be possible.

EUR/04/5045399 page 12 The Network enables all involved to get a better understanding of the issues through an open and constructive process, and the Declaration would create the opportunity to come together through annual meetings. As a result health policies in the regions would be better and this in turn would assist their home countries to function more effectively. Timis County in Romania introduced itself as a county on the border of Hungary and Serbia and Montenegro and the first Romanian region in the Network. It had partnership arrangements with North Rhine Westphalia and Baden Würtemberg and had formed a cross-border Euro-region including regions from Hungary, Romania and Serbia and Montenegro. Timis expressed gratitude to the Veneto region, with which it had signed a protocol agreement in 2002, for its help in arranging for the county’s attendance at the meeting. Many Italians live in Timis and representatives of the regions had exchanged visits. Timis concluded by presenting Veneto Region with gift from the county – a lion – the symbol of both Timis and Veneto. Carinthia expressed pleasure at being present as the Network’s newest member, for the first time. Carinthia was extremely pleased that a neighbouring region would be hosting a WHO Centre, and felt this to be a sign of WHO’s willingness to get close to the people of Europe. Carinthia fully supported the two year work programme, and especially the proposal on cross- border collaboration. There was already cross-border cooperation between Carinthia and neighbouring Italian regions Friuli-Venezia-Giulia and Veneto. Especially relevant were the project “trans-border cooperation in patient care” with Friuli-Venezia-Giulia and joint work in the area of prevention. The driving force for health policy development will need to be at regional level, as it is much easier there than at national level. An important task of the Network should be to ensure that national and community institutions are well informed so that decisions made on health issues can be fully implemented. This will be necessary to ensure that all citizens get care of equal quality and that cost reduction efforts do not create problems. Carinthia is working with Slovenia and Italy on a number of cross-border issues. A project called “trans-border practical training” including a student exchange programme within the areas of health and nursing education has recently been initiated with the Veneto region. Currently, arrangements for the creation of a common basic and advanced education and training centre with the two mentioned Italian regions are being made. These trans-regional activities will also be expanded to Slovenian regions after the accession of Slovenia to the European Union in May 2004. Carinthia wants to hear of others’ activities, especially regarding quality, and it has established links with South Tyrol. The involvement of politicians should strengthen the Network, which can be an international platform for further development. Wales spoke about the regional role and the future of the Network. Wales was a founding member of the Regions for Health Network, and some of the ideas underlying it had been developed in Cardiff in 1991. People from Wales have done a great deal with and for the Network in the past. Wales has shown its commitment to the Network and still believes in it. But it recognizes too that the RHN faces a number of challenges.

• It must have a clear role.

• It must make a real difference for all its members.

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• It must have a sound organizational and financial basis. The new work programme does create a distinctive set of task for the Network. Wales has agreed to lead on the policy development project. All should share their experience, and the range and depth of policies in the Welsh 10-year programme to improve health in Wales gives it a good understanding in this area. It has clear health gain targets. Its aim is a health service, not a sickness service, and it is committed to pursuing better health through all its policies. Wales offered to use its considerable experience in the field of health impact assessment to help develop a project on that topic also. Seeing these projects through successfully would benefit Wales and others. But to have sustainable, long-term success for the Network requires a clear identity, a sustained purpose, and a sound organizational and financial basis. The regions needed to play our part, and so did WHO. The present arrangements had served the Network well for its first 11 years, but this is now a different Europe, with new members. There might need to be changes – some suggestions were:

• replacing the Steering Committee by a Board

• establishing a Chair with a clear role

• agreeing to a five-year development plan with appropriate monitoring

• putting the budget on a firmer footing. While there are several organizations representing European regions, the Network is the only one focused on health and closely linked to WHO. If the regions seriously want to work together to improve health, they need to ensure that the relationships are right and the foundations are strong. Wales suggested that an early task for the Steering Committee should be a careful review of the current arrangements. Östergötland spoke on belief both of its own region and for Västra Götaland. The two regions share both the goals of the Network and a belief in its future. It said that the work programme contained eight well focused projects, all on high priority issues, which showed that the Network had met the challenge put to it in Copenhagen. Their outcome would help diminish the differences in health and service levels between the older European Union countries and the rest of Europe. It was very important that all should cooperate on this. However, it was also important to recognize that the threats that lay ahead. The uncertain financial situation in the Network might make difficult delivery of the work programme. Regions would do what they could. The strong commitment expressed by ministers and Dr Danzon gave confidence that WHO with the regions would work together to tackle problems that might appear, and so ensure that the work programme was delivered. Valencia expressed that though in recent years it had been unable to participate very actively in the Network, it had continued to contribute its subscriptions and its minister had signed the Adoption of Principles. At the Annual General Meeting in Teplice there had been alternative solutions proposed which would not require more funds, such as a stronger Secretariat, possibly through regions seconding officials and paying their salary. The issue was not simply finance, but finding new sources and strategies to support the work of the Network.

EUR/04/5045399 page 14 Dr Gava thanked all who had made contributions to the discussion, and concluded that the round table had been very encouraging and provided an optimistic view towards the future.

Response by the Regional Director of the WHO European Region

Dr Danzon reminded the participants that at the Copenhagen meeting, he indicated that he wanted to make an agreement with the Regions – each side should be very clear on what it should do, and do it. The budget of WHO had not been increased in ten years, though over that period the number of countries in the European Region of WHO had grown by 20, and the budget had been eroded by inflation. While the Regional Director would have liked to allocate more resources for RHN, it would be impossible to promise in the current situation. He would like to consider different arrangements as Wales and Östergötland had proposed. After 11 years of life, the Network was in a different environment. It must look hard at its present situation, as regards both its members and those interests outside it, select carefully the tools to enable it to promote its objectives, and ask for the help it needs. WHO is not in a position to allocate extra resources from its regular budget. Additional fundraising efforts from voluntary sources could only be successful where there were well defined objectives and clear projects. The Regional Director would be ready to discuss further steps with the Network, perhaps reorganized along the lines proposed by Wales, with a clear programme and clear outcomes. He promised to do his best to support regions in their resource mobilization efforts along these lines. Unfortunately, assessed contributions from Member States to WHO have not increased while demanding actions on diseases such as SARS, on poverty and other areas have increased. It is not possible for WHO to do more with less resources. The former WHO Director-General, Dr Brundtland, had asked Member States for a small increase in the budget but this proposal was not accepted. In the face of rising costs, he appealed to the regions to press their own governments to generate more resources for WHO’s work and accept that otherwise WHO cannot meet all additional needs and requests. In these circumstances, WHO could not provide more services to the Network. Dr Gava thanked Dr Danzon, and proposed that the Network accept this new challenge and see how to stimulate more income. He asked all to take this very seriously.

Adoption and signing of the Declaration and Conclusion

Dr Gava then moved that the Venice Declaration be adopted and this was agreed. High officials were invited to sign the Declaration, and, following this and his thanks to all who had attended and made the meeting a success, the meeting was closed.

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Annex 1

VENICE DECLARATION OF THE RHN

English Only

Venice Declaration of the RHN

WHO Regions for Health Network

Second Regional Ministerial Forum, 15 December, Venice This Venice Declaration complements the RHN Adoption of Principles document adopted at the First Regional Ministerial Forum in Copenhagen. On 15 December 2003, health ministers and other senior politicians representing the WHO Regions for Health Network (RHN) member regions met in Venice to attend the Second RHN Regional Ministerial Forum, as a follow up to the historic First Regional Ministerial Forum which took place on 24 June 2003 in Copenhagen at the WHO Regional Office for Europe. The WHO Regions for Health Network was established to promote health improvement at the regional level within countries and complement WHO’s country work. Today, there is a strong emphasis on developing common health policies through pan-European networks, cooperating on regional health systems and promoting links between regions. This political Declaration expresses the clear and strong commitment of regions throughout Europe and of WHO to work with each other, through implementing the biennial Work Programme 2004–2005. It is also a reaffirmation of the goals outlined in the RHN Adoption of Principles, adopted by health ministers at the First Forum in Copenhagen.

We, the Regional Health Ministers representing regions of the WHO Regions for Health Network, note that regions within countries across Europe are becoming an increasingly important power base for decision-making. There is a general trend towards multi-level governance, with greater power sharing between different levels of government resulting in multiple layers of authority across European, national and subnational levels.

We fully support the Network’s Work Programme 2004–20051, as confirmed by member regions at the 11th Annual Conference and General Meeting.

1 Annex I provides details to the first eight projects, for which leading regions have been determined.

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By doing so, we give concrete expression to the basic principles adopted in June – policy, information and quality:

Regions for Health Network Work Programme 2004–2005

—

—

—

—

Alcohol and Drug Related Harm Prevention

Cross-Border Health Tourism

Investment for Health

Joint Information Project – Mapping Regional Health Indicators (Core Project)

— Policy Exchange and Development (Core Project)

—

—

—

—

—

Public Health Strategies for Measles Elimination by 2010

Roma Health

Trauma Registry

Quality of Health Services *

Health Impact Assessment * * Leading regions to be confirmed

We confirm that regions are an appropriate level for the successful implementation of these projects. We have confidence that the above Work Programme will result in providing important evidence and tools for regions and for WHO.

We look forward to sharing the experiences of the Network, which will contribute significantly to efforts toward the universal goal of improving the health and well-being of all citizens.

We are committed to providing continual support through the Regions for Health Network, to ensure that health is placed high on political agendas. We expect the WHO Regional Office for Europe and the RHN Secretariat to strongly support the implementation of this Programme and related activities. Finally, we agree that there is a need for permanent annual consultations between WHO and the regional ministerial level.

Venice, 15 December 2003.

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Regions for Health Network (RHN) Work Programme 2004–2005

Alcohol and Drug Related Harm Prevention Leading Region: Västra Götalandsregionen

This project will develop a set of criteria which should be based on evidence, experience and good practice, by adopting the concept of the WHO Safe Community approach on prevention of alcohol. The Safe Community approach has shown to be effective in reducing accidents. In the same way alcohol and drug harm prevention criteria could be expected to have the same results in reducing alcohol- and drug-related harm. These criteria will be provided to municipalities and if politically committed they will facilitate the adoption of effective intervention strategies against alcohol and drugs. They will also make it easier for decision makers to identify potentially counterproductive policies. Projected Timetable The project will start in January 2004 and end in December 2005,

comprised of three phases: a) identification, 2) outline, and data collection and evaluation.

Priority areas involved Policy, Information, Quality, Child an Adolescent Health

Resources Each participating region cover their own costs; hosting regions cover the costs of common arrangements as venues, social arrangements etc.

Collaboration In the first phase participants should (a) identify a common set of criteria for policy and agree on how to approach different local communities and (b) outline a surveillance system. During the second phase the criteria are implemented via agreements with local communities within regions and agreements on how to perform the base line surveys. The third phase comprises data collection and evaluation of the process and outcome.

Final Products A set of criteria on good quality alcohol and drug preventive policy including guidelines for surveillance/mapping of alcohol/drug abuse.

Regions to be committed

Kaunas, Madeira, South Tyrol, Ticino, Usti, Varna, Vologda

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Regions for Health Network (RHN) Work Programme 2004–2005

Cross Border Health Tourism

Leading Region: Veneto

This project will focus on cross-border patient mobility and other health issues related to tourism. While the emphasis is often on emergency care, there are other issues such as related to with chronic conditions. This project would increase understanding of these issues and share experience, possibly building to provide a stable source of information and support for the EU. Projected Timetable The project would start May 2004 and be completed by May 2006.

Priority areas involved Policy and Information

Resources Funding expected from the new Public Health Programme 2004 or

ERANET Programme. Regions are expected to cover participation related to their Focal Points and travel two times per year to meetings.

Collaboration The first common meeting would set up way of working, which may involve that other regions would provide information on — —

— — —

citizens seeking health care abroad demand for medical services in EU and candidate countries, assessing both the health and the economic impact health services offered and the level of resourcing required costs of providing services for residents and tourists various health protection systems in use in the country

Final Products Guidelines and re-organizations of health services for tourists and bilateral agreements between regions

Regions to be committed

Catalonia, Carinthia, Madeira, North Rhine-Westphalia, Timis, Västra Götalands.

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Regions for Health Network (RHN) Work Programme 2004–2005

Investment for Health Leading Region: North West England

The North West launched its Investment for Health Plan in July 2003. It recognizes that action across sectors is required to improve health and reduce inequalities, which in turn produces economic and social benefits, and reduces the demand for health and social care. Integrated action is developing to ensure that all policies and programmes achieve these aims, for four agreed priorities – tackling the wider determinants of health, developing the good “corporate citizen” role of the National Health Service (NHS), reducing inequalities in service delivery, and strengthening primary care services. The “corporate citizen” priority has developed rapidly, with the recognition that health and social care systems are major economic, social, and environmental players. The health system has a vital role in securing wider regeneration, through its recruitment, training, employment, procurement, capital development, and other activities. North West England will collaborate with the Investment for Health Centre in Venice, and a group of regions from inside and outside the network, which have experience of developing this approach and are interested in taking it forward.

Projected Timetable Starting in January 2004, the initial collaboration will define a longer term programme which will include joint work between a group of regions and the Venice Centre, possible participation in EU programmes, such as Interreg IIIC, and a process to share experience within RHN.

Priority areas involved Policy, information, delivery programmes, capacity building. Resources The North West would be willing to host a meeting of interested

regions to define the programme. Resources for joint work, with the Venice Centre, and for EU programmes, will be defined and sought.

Collaboration The work with the Venice Centre would involve regions in: • Identifying concrete examples of how IfH processes and actions

have been incorporated into overall development frameworks. • Sharing experience of how partnership working across sectors

has contributed to policies and programmes which influence the wider determinants of health, and develop the good ‘corporate citizen’ role of the health sector.

• Providing learning and tools which support the application of IfH at the Regional level.

• Participating in annual Venice Centre Workshops to shape the application of IfH at the Regional Level.

Regions within possible Interreg Projects would be part of a learning network.

Final Products • Contributions to Venice Centre IfH development products. • Internal development reports. • Common, transferable methodologies and policies. • Technical reports on specific tools which can be jointly used and

promoted. Regions to be committed

The initial phase will establish commitment amongst regions expressing an interest in being involved: Catalonia, Kaunas, Valencia, Västra Götaland, Veneto, Wales, Usti. Other Regions would be free to participate in the initial phase.

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Regions for Health Network (RHN) Work Programme 2004–2005

Joint Information Project – Mapping Regional Health Indicators

(Core Project) Leading Region: North Rhine-Westphalia

Important preparatory work of a common data set has already been achieved by the Network through the development of a “Common Minimum Indicator Set”, a project led by North Rhine- Westphalia. This Joint Information Project would result in a geographical information system with an integrated tool for analysis. The “Health for All (HFA) Database,” developed by the WHO Regional Office for Europe, would be used as a base. The regional level had already been included when this software was developed. Regional data which are already available can be integrated into the system. As the HFA database interfaces for data integration have been described, it will be feasible for the regions to integrate their data in a standardised way into this database. If possible, compatibility with the data/indicators of other regional database projects, e.g. ISARE, should be achieved in a project carried out under the European Public Health Programme. Projected Timetable Development starts at the beginning of 2004 for this long-term

project. First discussions for preparation have started.

Priority areas involved Policy and Information.

Resources North Rhine-Westphalia provides concept input. Each region will then have to invest in their own indicator development. A second step would be to approach EU for funding.

Collaboration After project concept is set up, regional data which are already available are to be integrated into the system.

Final Product At the end of the project, indicators information from about 30 regions in Europe will be available for joint analysis. A report of the results would be made available.

Regions to be committed

The core group for the project concept development consists of: Emilia-Romagna, Kaunas, Madeira, Szabolcs-Szatmar Bereg, and Västra Götaland. As this is a core project, all regions would be requested to take part.

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Regions for Health Network (RHN) Work Programme 2004–2005

Policy Exchange and Development Project (Core Project)

Leading Region: Wales

If regions are to be able to compare policies and share experience and understanding, easy access to each other’s policies, priorities and plans is essential. Wales has developed an initial example of how a website might summarise major health policies in a region:

http://www.wales.gov.uk/subihealth/hscwb/hscwb-page1-e.htm The aim is an RHN standard that all regions could be asked to use to develop web pages. A standard web page format would provide an effective information base on which further analysis of policy development can be based. Projected Timetable The planned work would be complete by the end of 2004, but the

project would continue.

Priority areas involved Policy, and all areas covered by policy

Resources This project will initially require little if any central funding, as the responsibility will rest with the individual regions. However, WHO Regional Office will need to adapt its own web pages to reflect this work and allow fast access to the regional sites.

Collaboration All members have been invited to comment on an initial web site for presenting regional health policy and Wales is leading work with a small group on developing this idea further.

Final Products Subject to the views of the group and members, the aim might initially be an RHN standard for regional policy web pages. A second phase might include: — —

— —

the development of a model policy framework; the development of model policies for shared priority health areas; analysis of policies across the RHN; evaluation of selected policy areas across the RHN.

Regions to be committed

As this is a core project, all regions would take part.

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Regions for Health Network (RHN) Work Programme 2004–2005

Public Health Strategies for Measles Elimination by 2010

Leading Region: South Tyrol

Even with high coverage rates, measles epidemics may occur due to accumulation of susceptibles, underlining the necessity of well functioning surveillance and additional strategies like catch-up campaigns. The vaccine coverage with MMR is likely to differ significantly among the participating RHN regions. Factors which have been shown to significantly influence the vaccine coverage are vaccination schedules (mandatory versus recommended), offer free of charge, organizational aspects like active invitation, etc. This project will collect information on vaccination schedules, and organizational aspects (invitation, incentives, vaccination registries etc.), which will be obtained from partner regions with the aim of creating an inventory of what is currently in place. A case control analysis will depend on the number of regions participating. Coverage rates will be considered as outcome and all other aspects as risk factors. The objective is to identify the most important risk factors for low coverage in order to define recommendations. Projected Timetable The project is planned to start in January 2004. By March 2004 the

questionnaire should be sent to all participating regions, and by June a descriptive analysis on measles control should be available.

Priority areas involved Policy, Quality, Information, Child and Adolescent Health

Resources Each region takes over the own expenses related to the project. If a region is hosting a meeting, it takes over the expenses for the organization (not travel, board and lodging expenses of the single participants, except special social events organized by the region).

Collaboration — — — —

Establishment of specific working groups in the partner regions; Development of a common agenda; Meetings and exchange by e-mail; Presentation of results at annual RHN meeting.

Final Products Development of common strategies and guidelines for training, information and education regarding control of measles and training and workshops for health personnel.

Regions to be committed

Regions that have either implemented efficient/successful measles vaccination strategies or regions that are putting in place measles control/elimination measures.

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Regions for Health Network (RHN) Work Programme 2004–2005

Roma Health

RHN Leading Region: Györ-Moson-Sopron This project on the health of socially vulnerable groups is prompted by a problem that is attracting increasing attention in the Györ-Moson-Sopron region. There is little experience on how to tackle it, and awareness that a new methodology was required. This project would take upon case studies of the Roma people, a population which is relatively undereducated, poor and isolated. The principle aim of this project is to prepare key persons from the Roma population to act as helpers of their community and to participate in solution of local problems. Projected Timetable The Preparation stage will take place from January to April 2004.

The second stage of Training will take place from May to September 2004.

Priority areas involved Policy, Information, Mental Health and Child and Adolescent health.

Resources This project will run as a modest programme in Györ-Moson-Sopron county with a minimum amount of money. Additional funding possibility to be considered is to collaborate with other regions in applying for EU funds. Along with providing leadership in the project, Györ-Moson-Sopron can provide technical organisation for the methodology guidebook.

Collaboration Case studies and experiences on helping the Roma populations from other regions are sought.

Final Product Guidebook with guidelines based on experience and completed with a methodology, including case studies from programs involving Roma population in Hungary and participating RHN regions.

Regions to be committed

Szabolcs-Szatmár-Bereg, Usti and other regions with Roma populations.

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Regions for Health Network (RHN) Work Programme 2004–2005

Trauma Registry

Leading Region: Kaunas The Trauma Registry is an information system of the most seriously injured patients and the treatment that they have received. The purpose of the registry is to evaluate the quality of trauma patient care and to plan and evaluate injury prevention programs. The criteria (to be discussed) for inclusion in the trauma registry are patients with injuries who are admitted to hospital, held for observation, transferred to another acute care hospital, or declared dead in the emergency department, and for whom contact occurred within 30 days of the injury. Injuries include trauma, poisoning, suffocation, and the effects of reduced temperature. Projected Timetable 2004–2006, depends on number of regions involved (at least 5) and

successful application to the EU Public Health program.

Priority areas involved Policy, Quality, Information, Environment

Resources Kaunas region (Regional Public Health Center, Kaunas University of Medicine, National Health Information Center) will draft the project proposal providing sufficient manpower and necessary finances.

Collaboration Other interested RHN member regions will be requested to provide necessary information and suggestions for application. The project will be implemented following these guidelines: • Evaluation of existing registration forms and accessible

information; • Preparation of the unified registration forms; • Preparation of registration forms for use in computerized database; • Design of database and registry network; • Purchasing computer and telecommunication equipment (if

needed); • Decision on Criteria for Trauma registry; • Pilot study; • Publishing and implementation of registration forms; • Training of personnel; • Spreading of information (workshops/conferences) – presentation

of the Trauma registries for the network and within the regions; • Evaluation of the project.

Final Products Database: Trauma registry at the regional level as a tool for information, heath policy formulation, continuous quality improvement in related health care sectors.

Regions to be committed

To be confirmed.

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Venice Declaration signed 15 December 2003 Page 1/2

Armenia Sunik

Austria

Carinthia

Bulgaria

Varna

Czech Republic, Moravia-Silesia

Czech Republic Usti

Germany

North Rhine- Westphalia

Hungary

Györ-Moson- Sopron

Hungary

Szabolcs-Szatmar

Italy

South Tyrol

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Venice Declaration signed 15 December 2003 Page 2/2

Italy

Veneto

Lithuania

Kaunas

Poland

Upper Silesia

Portugal Madeira

Romania

Timis

Russian Federation

Vologda

Sweden

Östergötland

United Kingdom

North West England

United Kingdom

Wales

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Venice Declaration signed after the meeting on 15 December 2003 Page 1/1

Belgium

Flemish Community

Italy Tuscany

Spain Catalonia

Spain Valencia

Sweden Västra Götaland

Switzerland Ticino

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Annex 2

FINAL LIST OF PARTICIPANTS

RHN MEMBER REGIONS Armenia – Sunik Region Dr Zhasmen Stepanyan* Chief, Sunik Region Department of Public Health Services Care and Social Affairs 5 Toumanian st. Art. 8 377 810 Kapan Austria – Carinthia Dr Peter Ambrozy Vice President Region of Carinthia Amt der Kärntner Landesregierung Arnulfplatz 2 A-9020 Klagenfurt Dr Hugo Tschernutter* Head, Social Policy and Health Legislation Regional Government of Carinthia Amt der Kärntner Landesregierung Arnulfplatz 2 A-9020 Klagenfurt Dr Petra Oberrauner ECC Euralp Crossborder Consulting Moritschstrasse 2/2 9500 Villach Mr Gerald Passegger Amt der Kärnter Landesregierung Arnulfplatz 2 9020 Klagenfurt Mrs Claudia Roseano Amt der Kärnter Landesregierung Arnulfplatz 2 9020 Klagenfurt

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Bulgaria – Varna Dr Zdravko Markov Regional Minister of Health Municipality of Varna Varna Regional Health Directorate 43 Osmi Primorski polk st. 9002 Varna Professor Stoyanka Popova* Dean Medical University of Varna Faculty of Public Health Marin Drinov str 55 9002 Varna Czech Republic – Moravia-Silesia Mr Jirí Carbol Deputy Regional President Moravian-Silesian Regional Authority 28. ríjna 117 70218 Ostrava Dr Jaroslav Volf* National Institute of Public Health Srobarova 48 10042 Prague 10 Mrs Dagmar Adamova Head, Health and Social Committee Moravian-Silesian Regional Authority 28 rijna 117 70218 Ostrava 2 Dr Helena Sebakova Regional Public Health Authority Northern Moravia Regional - Ostrava Na Belidle 7 70200 Moravska Ostrava Czech Republic – Usti Region Mr Vladimir Zahorsky Regional Minister of Health Usti Region Husova 422 440 01 Podborany

EUR/04/5045399 page 30 Dr Josef Richter* Regional Institute of Public Health Moskevska 15 400 01 Usti nad Labem Dr Stanislava Richterova Director Regional Institute of Public Health Moskevska 15 400 01 Usti Nad Lasem Mrs Martina Skvarova Regional Institute of Public Health Moskevska 15 400 01 Usti nad Labem Mr Miroslav Strachal Finance Director Regional Institute of Public Health Moskevska 15 400 01 Usti nad Labem Germany – North Rhine-Westphalia Mrs Cornelia Prüfer-Storcks State Secretary Ministry of Health, Social Affairs, Women and Family North Rhine-Westphalia Fürstenwall 25 40219 Düsseldorf Dr Birgit Weihrauch* Ltd. Ministerialrätin Ministry of Health, Social Affairs, Women and Family North Rhine-Westphalia Fürstenwall 25 40219 Düsseldorf Hungary – Györ-Moson-Sopron Mr Matyas Firtl Deputy President General Assembly of the County of Györ-Moson-Sopron Arpad ut. 32 9021 Györ

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Dr Erzsebet Bazsika* Head of Health Promotion Department Public Health Institute (ANTSZ) Györ-Moson-Sopron County Josika u. 16 9024 Gyor Hungary – Szabolcs-Szatmar Bereg Dr Gabor Kiss Deputy President of the General Assembly Szabolcs-Szatmar-Bereg County Hösök tere 5 4400 Nyiregyhaza Dr Marianna Penzes* Public Health Office Arok ut. 41 H-4400 Nyiregyhaza Ms Bella Balazsy Autonomous Government of Szabolcs-Szatmar-Bereg County Hösök tere 5 4400 Nyiregyhaza Italy – Emilia-Romagna Dr Marco Biocca Agenzia Sanitaria Regionale dell’Emilia-Romagna Regional Health Agency of Emilia-Romagna Via Aldo Moro 21 40127 Bologna Italy – Sicily Dr Pina Frazzica* Director General Centre for Training and Research in Public Health – CEFPAS Via G. Mulè, 1 I-93100 Caltanissetta Italy – South Tyrol Dr Otto Saurer Minister South Tyrol Ministry for Health and Social Affairs of the Autonomous Province of South Tyrol Freiheitsstrasse 23 I-39100 Bolzano

EUR/04/5045399 page 32 Dr Giulia Morosetti* Director Health Department 23 Autonomous Province South Tyrol Corso Libertà 23 I-39100 Bolzano Italy – Veneto Dr Fabio Gava Vice President of the Veneto Region Regional Minister of Health Veneto Region Palazzo Balbi Dorsoduro 3901 I-30125 Venice Dr Franco Toniolo General Director for Health and Department of Health Veneto Region Social Services Palazzo Molin San Polo 2513 I-30125 Venice Dr Luigi Bertinato* Director Office for International Public Health and Social Programmes Department of Health Veneto Region Campo Santa Marina, Castello 6074 I-30122 Venice Lithuania – Kaunas region Dr Henrikas Ceida Regional Minister of Health Governors Administration of Kaunas County L. Sapiegos 10 LT-3000 Kaunas Professor Zilvinas Padaiga* Prorector Kaunas University of Medicine A. Mickeviciaus str. 9 LT-3000 Kaunas

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Poland – Upper Silesia Mrs Malgorzata Ocheduszko Ludwig Vice Chairman of Regional Parliament Silesian Seym Sejmik Wojewodztwa Slaskiego Ligonia 46 40037 Katowice Dr Jacek Czapla* Director Department of Social Policy Silesian Voivodship Office ul. Powstancow 41a PL-40024 Katowice Portugal – Madeira Dr Conceição Estudante Regional Secretary Social Affairs Rua das Hortas 30 9050-024 Funchal Portugal Dr Miguel Stringer Pestana Coordinator Regional Office for Social Affairs Rua das Hortas no. 30 P-9050-024 Funchal, Madeira Portugal Romania – Timis Region Mr Constantin Ostaficiuc Vice President Timis county 17 Revolutiei Bvd 1900 Timisoara Dr Dana Paica* Timis County Council Bdl. Revoluties 1989 Nr. 17 1900 Timisoara

EUR/04/5045399 page 34 Russian Federation – Vologda Dr Alexander A. Kolinko* Head Public Health Management of the Vologda Administration 2, Hertzen Str. 160035 Vologda Spain – Catalonia Dr Ricard Tresserras* General Direction of Public Health Pavello Ave Maria Department of Health and Social Security Public Health Division Travessera de les Corts 131-159 E-08028 Barcelona Spain – Valencia Dr Carmen Sanchis Piñol* Head Valencia School of Health Studies International Programmes C/ Juan de Garay 21 E-46017 Valencia Sweden – Östergötland Mrs Agneta Niklasson Regional Minister The County Council of Östergötland St. Larsgatan 49B S-581 91 Linköping Dr Birgitta Larsson* Project Manager County Council of Östergötland St Larsgatan 49B S-581 91 Linköping Sweden – Västra Götaland Dr Göran Henriksson* Senior Public Health Adviser Folkhälsokommitténs Kansli, Regionens hus Västra Götaland Region S-54 287 Mariestad

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Switzerland – Ticino Professor Gianfranco Domenighetti* Head Departamento delle opere sociali Sezione sanitaria (DOS) Via Orico 5 CH-6500 Bellinzona United Kingdom – North West England Mr Dave Quayle Councillor North West Regional Assembly Wigan Investment Centre, Waterside Drive Wigan WN3 5BA Mr Peter Flynn* Deputy Regional Director, Public Health North West Public Health Team Government Office for the North West Department of Health Directorate of Health and Social Care Room1816, Sunley Tower, Piccadilly Plaza Manchester M1 4BE United Kingdom – Wales Ms Jane Hutt Minister of Health and Social Services National Assembly for Wales Cathays Park GB-Cardiff CF99 1NA Mrs Ann Lloyd Director, Health and Social Care NHSD Welsh Assembly Government Cathays Park GB-Cardiff CF99 1NA Mrs Margaret Davies National Assembly for Wales Cathays Park GB-Cardiff CF99 1NA

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OBSERVER REGIONS Italy – Campania Region Mrs Rosalba Tufano Italy – Tuscany Region Giorgio Almansi Region of Tuscany Department of Right to Health Via di Novoli, 26 I-50100, Florence Mrs Maria Jose Caldes “A. MEYER” Children’s University Hospital Via Pico della Mirandola 24 50133 Florence Mrs Katalin Majer “A. MEYER” Children’s University Hospital Via Pico della Mirandola 24 50133 Florence Maria José Caldés Pinilla “A. MEYER” Children’s University Hospital Via Pico della Mirandola 24 I-50133, Florence Mr Fabrizio Simonelli “A. MEYER” Children’s University Hospital Via Pico della Mirandola 24 50133 Florence Mrs Donatella Tanini Region of Tuscany Department of Right to Health Via di Novoli, 26 I-50100, Florence Lithuania – Panevezys Region Dr Raimonda Ulianskiene Panevezys County Governor's Administration Respublikos 38 LT-5300 Panevezys

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Russian Federation – Chuvasia Region Mrs Nina Suslonova Regional Minister of Health Republic of Chuvashia Uritzky str. 43 Cheboksary 428004 Mrs Natalia Belova Director, Health Insurance Foundation c/o Ministry of Health Chuvash Republic Uritzky str. 43 Cheboksary 428004 Dr Mary Collins, WHO Health Care Policy Adviser WHO Office for the Russian Federation 28 Ostozhenka Street 119034 Moscow Professor Serguei Volkov Project Interpreter Moskovsky prospect 45 Cheboksary 428017, Chuvashia

SPEAKERS Dr Josep Figueras Head, European Centre for Health Policy c/o Service public fédéral (SPF) Santé publique, Sécurité de la Chaîne alimentaire et Environnement Montagne de l'Oratoire 20, boîte 3 B-1010 Brussels Belgium Professor Klaus Hurrelmann Director Faculty of Public Health University of Bielefeld WHO Collaborating Center for Child and Adolescent Health Promotion PF 100 131 D-33501 Bielefeld Germany

EUR/04/5045399 page 38 Dr Erio Ziglio Head WHO European Office for Investment for Health and Development Campo Santa Marina, Castello 6073 I-30122 Venice Italy

REPRESENTATIVE FROM THE EUROPEAN COMMISSION Mr Dario Zanon Detached National Expert EuropeAid Co-operation Office European Commission Rue de la Loi/Weststraat 41 1040 Brussels Belgium

HOST REGION

Brussels office Mrs Mariantonietta Fresu Mrs Eleonora Martinello Mr Francesco Ronfini Veneto Region – Brussels Office Rue de l’Industrie 22 1040 Brussels Belgium

RAPPORTEUR Dr Christopher Riley United Kingdom

WORLD HEALTH ORGANIZATION Regional Office for Europe Mrs Albena Arnaudova, Communication Officer Dr Roberto Bertollini, Director, Division of Technical Support – Health Determinants Dr Marc Danzon, Regional Director Mrs Birthe Havn, Programme Assistant, Regions for Health Network Mrs Wendy Tse Yared, Coordinator for the Regions for Health Network * = Focal Point for the Regions for Health Network

ABSTRACT CONTENTS Keywords Opening session Welcome by the Minister of Health for Veneto Region Welcome by the Regional Director of the WHO European Region Greetings from the European Commission Presentations Regions and the WHO European Office for Investment for Health and Development Health systems decentralization – The role \(and Health information and regional cooperation – exp

The round table discussion Introduction Contributions

Response by the Regional Director of the WHO European Region Adoption and signing of the Declaration and Conclusion Annex 1 - Venice Declaration of the RHN Regions for Health Network (RHN) Work Programme 2004–2005 Alcohol and Drug Related Harm Prevention Cross Border Health Tourism Investment for Health Joint Information Project – Mapping Regional Health Indicators Policy Exchange and Development Project (Core Project) Public Health Strategies for Measles Elimination by 2010 Roma Health Trauma Registry

Annex 2 FINAL LIST OF PARTICIPANTS