Algarve’s regional authorities have proven to be fully aware of the need to embed health issues in SF programme design at strategic level. These authorities agree to consider the promotion of a healthy living and working environment as crucial to the region’s attractiveness, productivity levels and social inclusion.However, Operational Programme Managing Authority representatives pointed out that the contribution of regional health authorities had so far remained “very traditional in nature” since they overwhelmingly consisted of infrastructure project proposals. These representatives also insisted upon the difficulties of trying to gather stakeholders around initiatives with a rather intangible referent such as health gains.

Health is considered in Algarve’s OP under several different dimensions. The most prominent one is health infrastructure, which is defined as a priority for the regional development strategy due to risks arising from insufficient health professionals and hospital beds, especially given the recurrent population increase between July and September. The economic potential of the health care sector, is likewise acknowledged. Furthermore, the programme recognises the importance of health to increase productivity levels of the economy and promote social inclusion. Lastly, the promotion of healthy and sustainable living and working environments is considered by officials in the managing authority as a top priority for Algarve’s tourism-based competitiveness and economic development.  

Algarve’s 2007-2013 OP comprises non-health interventions with significant potential health gains. These namely include urban regeneration projects, measures to ease social conflicts, preservation of natural spaces, sustainable tourism promotion, and healthier and safer urban mobility. Incentives for the private sector to invest in the improvement of occupational hygiene, safety and health conditions also fall within this category.

The OP also foresees the co-financing of a number of direct investments in health. Within this category, the bulk of EU assistance has been allocated to collective health care and social assistance equipment and infrastructure including the construction of new primary health care units as well as the renewal and adaptation of existing units. These interventions are smaller and more targeted in nature compared to the 2000-2006 period, during which a significant number of social infrastructure projects including health were carried out.

Algarve’s Regional Health Authority (ARS) has participated in a significant number the meetings called by the Managing Authority to prepare and coordinate the region’s OP. ARS representatives talk of “a long-standing relationship of trust and communication”. However, ARS’ contributions to the OP were deemed to be “very traditional” in nature by officials in the Managing Authority since they mainly consisted of infrastructure project proposals

A number of shortcomings have been pointed out by consulted officials with regard to the assessment of health gains from non-health investments.

First, it is “crucial to further institutionalise the dialogue between health authorities and Structural Fund authorities, so that it becomes less dependent on personal affinities or inclinations”.

Second, substantial difficulties exist to gather stakeholders around initiatives with a rather intangible referent such as health gains, as concrete infrastructure projects tend to be much more visible and politically profitable. In the same vein, public consultations on these issues raise little interest beyond experts and usually fall short of mobilising a wide range of stakeholders.

Third, the context and monitoring indicators currently promoted by the European Commission for Structural Funds programming, which are often output- and process-based, does not necessarily provide a suitable framework for potential health gains of planned investments to be taken into account. This may call for a broader vision attaching greater importance to qualitative aspects and outcome-based indicators.

As far as the web-based guide is concerned, consulted officials observed that it could be most useful by showcasing good practices involving public health considerations in Structural Funds programming. It could also help disseminate information about relevant conferences and discussion fora, and, to the extent possible, contribute to experience sharing and partnerships among stakeholders. This would enable better informed decisions in the context of the post-2013 Cohesion Policy programming, including ex-ante assessments of the Operational Programmes.

Regarding the guide’s features, simplicity (including printable outputs) and clarity were highly praised, “particularly given current resource constraints in many managing authorities”, as is the provision of operational and comparable indicators allowing for timely programme redesign/reorientation whenever results are proven to be unsatisfactory.

Finally, the guide should clearly and explicitly refer to Cohesion Policy spending categories to maximise operational usefulness and enable better targeted action. 

Background Information

The Algarve is Portugal’s southernmost region. Its surface nears 5,000 sq. km or 5% of the country’s total area and coincides with the Faro district. It encompasses 16 municipalities and limits with the Alentejo region (north), the Atlantic Ocean (west and south) and the Spanish region of Huelva (east).

The Algarve has approximately half a million permanent residents[1] (4% of the country’s total) and a population density of 85.7 inhabitants per sq. km. Population, however, usually reaches one million during summertime. Apart from large urban areas such as Lisbon and Porto, the Algarve is the country’s only region to register population growth.

In 2008, the region’s GDP amounted to EUR 9,18bn in PPS, that is EUR 21,500 per capita in PPS or 86% of the EU27 average (PPS). Due to the importance of tourism, economic activity is heavily concentrated by the tertiary sector, which nears 80 to 85%% of GDP compared to 10-12% and 4-5% for, respectively, the secondary and primary sectors.    

Table 1: Algarve - the region at-a-glance

 

Population (inh., 2009)

434,0023

Surface area (km2)

4, 988.56

GDP per capita in EUR (PPS, 2008)

21,500

GDP per capita as % of EU 27 (PPS, 2008)

86%

Cohesion Policy status

Convergence (phasing out)

Life expectancy at birth, male (2008)

74.8 (74.9)*

Life expectancy at birth, female (2008)

81.5 (81.5)

Sources: Eurostat and Fifth report on economic, social and territorial cohesion, Portugal National Institute for Statistics (INE), Portugal’s Office of the High Commissioner for Health).

* Average for 2007-2009, according to Portugal’s Office of the High Commissioner for Health.

 

Figure 1: GDP per capita in PPS (EU27 average = 100)

 

 

Source: Eurostat.

Figure 2: Portuguese regions, by Cohesion Policy status, 2007-2013

Source: DG Regional Policy – Inforegio

 

In 2008, life expectancy at birth in Algarve was 74.8 years for men and 82 years for women, which is slightly below the EU 27 average of 75.8 (men) and 82 (women).

Despite being wealthier than the national average (see figure 1 on the previous page), the region shows noteworthy shortcomings in terms of overall development. It ranks particularly low on the EU version of the UN’s Human Development Index (HDI)[2], which includes healthy life expectancy, household income, and educational attainment levels. In 2007, Algarve scored 30 out of 100 compared to an average value of 62 for the EU as a whole.

 

Policy and institutional overview

 

Cohesion Policy

 

Overview

Under the current programming period, Algarve is a Convergence region with phasing-out status, which means frontloading of EU regional development assistance in the first years of the period. Algarve’s 2007-2013 Operational Programme (Programa Regional Operacional do Algarve) only concerns ERDF assistance, as ESF assistance is administered at national level by means of the Thematic OP “Human Potential” (Programa Operacional Temático Potencial Humano). A part of ERDF assistance to Portugal is likewise channelled through two national thematic OPs: “Competitiveness Factors” (Factores de Competitividade) and Land Planning (Valorização do Territorio), which also includes ESF assistance.

Algarve’s OP sets out the regional development strategy for the period to end 2013. The programme explicitly acknowledges the need for efficient policy design and project management to fully leverage on Structural Funds assistance to the region during the current period, as these funds are likely to drop significantly after 2014.  

Managing institutions

The Managing Authority comprises a Directing Commission and a Technical Secretariat. The Directing Commission, whose members are appointed by the National Government, is chaired by the President of Algarve’s Regional Development and Coordination Commission (Comissão de Coordenação e Desenvolvimento Regional, CCDR). It also encompasses two representatives from the Ministerial Commission for the Coordination of all OPs (Commissão Ministerial de Coordenação do Conjunto dos PO Regionais do Continente), which is in charge of providing the main political guidelines, and another two from the National Association of Portuguese Municipalities. The Technical Secretariat provides administrative, logistic and technical support to the Directing Commission.

 

Health sector

The level of competence devolved to regions in Portugal is an administrative one (nível administrativo), except for the Autonomous Regions of Madeira and Açores, which are namely comparable to Spanish regions in that regard.

At national level, the main guidelines for Portugal’s health policy are contained in the National Health Plan of the Ministry of Health. This multi-year plan was last released for the period 2004-2010, whereas approval and release of a National Plan for 2011-2016 are still pending.

The main health policy document for the Algarve region is the Directing Health Plan (Plano Director de Saúde do Algarve), which draws on the National Health Plan and is translated into yearly Regional Health Action Plans (Plano de Acção Regional da Região de Saúde do Algarve). The Regional Health Authority of Algarve (ARS), which has a department specifically devoted to public health, is in charge of implementing health policies in the region.

According to Public Health Department Director of Algarve’s ARS, the following are the main health policy objectives for the Algarve region:

§  Enhance access to long-term health care

§  Enhance health promotion and preventive health care initiatives, with a particular focus on cancer prevention and early screening

§  Consolidate health care reform in Portugal, with primary health care as priority

 

Health in the Structural Fund programmes

 

A review of the 2007-2013 Operational Programme for Algarve shows that, while direct spending on healthcare remains high on the agenda, the impact of non-health investments on health gains has been taken into account, particularly in the strategic analysis of the region. The socioeconomic implications of health outcomes also seem to be among the main concerns expressed in the programme.

Health as a priority

Health is considered in the OP’s Analysis of the regional situation. More precisely, it lists four health-related context indicators. It is noteworthy that, in addition to resource-based indicators (medical doctors/dentists per 100,000 inhabitants, hospital beds per 1,000 inhabitants), the analysis takes the infant mortality rate into account. In its SWOT analysis, this section of the programme stresses the risks arising from insufficient health professionals and hospital beds, especially given population increase between July and September every year. Health infrastructure is therefore defined as a priority for the regional development strategy.

The OP’s Analysis of the regional situation stresses the potential of the health care sector, as well as the so-called health tourism, as factor of economic development for the region. The OP’s first priority axis on Competitiveness, Innovation and Knowledge, in turn, mentions explicitly the strengthening and further development of the “tourism and laser cluster” (cluster do Turismo e Lazer) among the interventions to be carried out under the axis.

In section 3, which summarises the regional development strategy, Algarve’s OP acknowledges the importance of health to increase productivity levels of the economy and promote social inclusion.

Investment in health

Support to the nation-wide reform of the system of incentives for private sector investment is at the core of the OP’s first priority axis. This reform seeks to increase competitiveness levels. The typology of investments to be co-financed by the ERDF in this context includes those oriented to the improvement of occupational hygiene, safety and health conditions.

Investments in health are foreseen in the third priority axis, Land planning and urban development, which otherwise acknowledges quality of life as a key challenge associated with regional economic development. More precisely, within the context of urban regeneration, the OP defines its main objective as the development of healthy and sustainable urban centres, which notably includes the development of green corridors and cycling pathways and the regeneration of degraded buildings. In order to enhance the competitiveness of the region’s urban network, this axis also foresees investments in collective equipment and infrastructure in areas including health care and social assistance.    

The table on the next page summarises the key priorities and intervention areas of Algarve’s OP, as well as their correlation with the proposed briefing sheet topics. Whenever applicable, the table also shows how health is considered within each priority.


Table 2: Overview of Algarve’s OP

 

Algarve Regional OP 2007-2013 (ERDF only)

MA:  Regional Development and Coordination Commission (Comissão de Coordenação e Desenvolvimento Regional , CCDR)

Total EU allocation: € 175m

PriorityAxis

Funds (€m)

Percent of total OP

Content of priority

Briefing Sheet topic(s)

Health considerations in the priority

Competitiveness, Innovation and Knowledge

90

51.43%

 

Support to competitiveness and innovation of enterprises

Support restructuring of economic activities

Valorisation of the Tourism and Laser Cluster

Modernisation of the Public Administration Development of the Knowledge Society

Institutional promotion of the region

Institutional capacity

ICT

Tourism

Improvement of occupational hygiene, safety and health conditions is acknowledged as source of increased competitiveness

Environmental protection

18

10.29%

Protected areas and biodiversity

Reduction, reuse and recycling of waste

Promotion of environmental quality and energy efficiency

Prevention of natural and technological risks

Valorisation of coastal areas

Biodiversity

Energy

Infrastructure: waste

 

Territorial and urban development

61

34.86%

 

Urban regeneration

Competitiveness of the regional urban network

Accessibility and mobility of the urban system

Territorial cohesion in low-density areas / economic valorisation of endogenous resources

Valorisation of the Guadiana and Arade basins

Urban and rural regeneration

Transport

Development of healthy and sustainable urban centres

Investments in collective equipment and infrastructure in areas including health care and social assistance

Technical assistance

6

3.43%

 

Cross-cutting

N/A

 

Total Algarve OP 2007-2013

175

100%

 

 

 

 

 

 


Integrating health in the programmes

 

This section covers the process and experience with integrating public health issues into the planning of Algarve’s ERDF OP as well as the implementation and monitoring, where applicable. It is based primarily on interviews with managers and experts in the Structural Funds managing authority and the regional health authority. A list of interviews conducted is contained in the References section of this report.

According to the Division Head of Regional Studies in the managing authority, public health considerations have been built into Algarve’s regional development planning over the years. These considerations are today fully internalised by the regional development strategy (which has tourism activities at its very core) as gauge of sustainability and competitiveness.

Targeted interventions to improve the well-being and quality of life in the region are the main focus of Algarve’s 2007-2013 OP according to this official. These namely include urban regeneration projects, measures to ease social conflicts, preservation of natural spaces, sustainable tourism promotion, and healthier and safer urban mobility. The targeted nature of interventions in the current programming period also obeys to a two-thirds drop in Structural Funds assistance to the region compared to the 2000-2006 period, during which a significant number of social infrastructure projects including health were carried out that have allowed for quality service networks to be presently in place.

This view is endorsed by the Public Health Department Director of the Regional Health Administration of Algarve (ARS), for whom a number the health policy objectives have been integrated into Structural Fund programming documents. He cited the following types of investments as having been particularly successful in addressing health determinants: water treatment and water supply infrastructures; tourism (“which creates wealth and thus indirectly promotes healthier habits”); and education (“which is consistently associated with healthier lifestyles”). This official also noted that the reform of the health system is being partially financed by EU grants. This involves the construction of new primary health care units as well as the renewal and adaptation of existing units.

Consultation with health sector in the 2007-2013 programmes

Portugal’s Ministry for Health, and the ARS on its behalf, have been involved in the preparation and coordination of the region’s ERDF Operational Programme. This preparation consisted of meetings on the following topics: infrastructure, social integration and cohesion, and environment.

According to the ARS Public Health Department Director, the Regional Health Authority of Algarve has always been consulted within the framework of Structural Funds programming so that “a long-standing relationship of trust and communication exists with the Structural Funds managing authority in the region”. Consultations typically took place through both formal and informal channels. This official stated that intense communication and negotiations also take place between the ARS and decision-makers and stakeholders at regional and local level, in accordance with the Health in All Policies (HIAP) approach.

This official also pointed out that, beyond the Structural Funds remit, the Regional Health Authority of Algarve cooperates actively with authorities in the fields of employment and environment, although this cooperation has not translated into any joint plans/programmes so far.

Whereas the Division Head of Regional Studies in the Managing Authority confirmed that Algarve’s ARS had taken part in a significant number of the meetings held, he described ARS’ contributions to the OP as being “very traditional” in nature. According to this official, they overwhelmingly consisted of infrastructure project proposals. He suggested that this response by the ARS has to do with “firmly implanted working dynamics entailing a systematic bias toward direct investments in health, even though this is inconsistent with the overall approach of Algarve’s current regional development strategy”. 

Further needs

According to Algarve’s ARS Public Health Department Director, appropriate and timely assessment of the impacts on health of non-health Structural Funds investments requires constant dialogue between health authorities and Structural Fund authorities. According to this official, it is “crucial to further institutionalise this dialogue, so that it becomes less dependent on personal affinities or inclinations”.

In addition, the Division Head of Regional Studies in the managing authority noted that, despite ongoing efforts, it continues to be difficult to gather stakeholders around initiatives with a rather intangible referent (health gains). Concrete infrastructure projects are in turn much more visible and thus more profitable in political/electoral terms. Public consultations on indirect life quality gains (including health) from investments encounter comparable obstacles: “they raise little interest beyond experts and usually fall short of mobilising a wide range of stakeholders”.

According to this official, the context and monitoring indicators currently promoted by the European Commission for Structural Funds programming, which are often output- and process-based, do not necessarily provide a suitable framework for potential health gains of planned investments to be taken into account. A broader vision attaching greater importance to qualitative aspects and outcome-based indicators would be more advantageous for this purpose.

References

Print sources

Administração Regional de Saúde do Algarve: Plano de Acção Regional da Região de Saúde do Algarve (Regional Health Action Plan), October 2007.

Quadro de Referencia Estrategico Nacional: Programa Regional Operacional do Algarve 2007-2013 (Algarve Regional Operational Programme).

Quadro de Referencia Estrategico Nacional: Programa Operacional Temático Potencial Humano 2007-2013 (Thematic OP “Human Potential”, co-financed by the ESF)

Quadro de Referencia Estrategico Nacional: Programa Operacional Temático Factores de Competitividade (Thematic OP “Competitiveness Factors”, co-financed by the ERDF)

Quadro de Referencia Estrategico Nacional: Programa Operacional Temático Valorizacao do Territorio(Thematic OP “Land Planning”, co-financed by the ESF and the ERDF)

[All OPs available on: http://www.qren.pt/item3.php?lang=0&id_channel=34&id_page=203]

Health and Structural funds in 2007-2013: country and regional assessment, Country assessment Portugal, EUREGIO III project for DG Sanco, 2009. http://ec.europa.eu/health/health_structural_funds/used_for_health/index_en.htm

WHO, Regional Office for Europe: WHO Evaluation of the National Health Plan of Portugal (2004–2010), 2010.

 

Interviews

Interviews with Algarve’s Regional Health Authority:

Dr Francisco Mendonça, Official at the Administração Regional de Saúde do Algarve (ARS, Regional Health Authority of Algarve), 17 April 2011.

Interviews with the Managing Authority:

Dr António Ramos, Division Head of Regional Studies at the CCDR, 5 May 2011.



[1]434,023 inhabitants in 2009 according to Portugal’s National Institute for Statistics. Population density figures are for 2008.

[2]Cohesion Policy Report.