The role of participation and intersectoral cooperation in mainstreaming public health into non-health Structural Funds programming.

As regards regional strategic planning, Andalucía boasts a remarkable participation-oriented institutional infrastructure. The region’s record in intersectoral cooperation includes joint strategies, plans and programmes in areas such as energy, climate change and disabilities. Public health falls, however, short of being systematically integrated into Structural Funds planning as this integration remains heavily dependent on whether interventions are managed directly by regional health authorities. Considering health implications of Structural Funds investments only implicitly is another shortcoming. More stable partnerships and strategic coordination earlier on in the planning process have been identified as important levers for progress to this regard.

Public health is considered from a different perspective in each of Andalucía’s Operational Programmes.

In its ERDF OP, health is predominantly considered under its health care/health services dimension, and strategic considerations regarding health are dominated by the potential benefits of direct investments in health. 

Andalucía’s ESF OP adopts a broader approach insofar as it stresses the need to use Structural Funds as a means to protect those social groups that are most vulnerable to health risks, such as drug addicts, the socially excluded or the disabled. It also focuses on occupational risk prevention as well as on the public health dimension of socioeconomic inclusion, including the need to reduce gender inequalities.

The main reference for the preparation of the region’s Operational Programmes has been Andalucía’s Regional Strategic Framework document (Marco Estratégico Regional de Andalucía (MER-AN) 2007-2013), which is the region’s contribution to the NSRF. Andalucía’s Economic Policy Commission was responsible for coordinating the participation of all relevant stakeholders in the preparation of both the Regional Strategic Framework and subsequent Operational Programmes. In October 2005, the Economic Policy Commission invited all regional Ministries, including the Regional Ministry for Health, to submit their draft sectoral strategies and proposals for the use of Structural Funds. A working group on the promotion of socioeconomic agents’ participation in regional planning, and a series of workshops involving representatives from the academia and the civil society, were also instrumental in the preparation of Andalucía’s development strategy.

Despite this participation-oriented institutional architecture, there seems to be still room for improvement as far as the integration of health considerations in regional planning is concerned.

Firstly, formal invitations by the Economic Policy Commission have not translated into effective consultations in all cases.

Secondly, health implications are often considered only implicitly (“since selected projects have to comply with regional, national and EU legal requirements, then their impact on health can only be positive”), which entails strong risks of overlooking major potential health impacts, and also fails to capture the health gains from non-health investments.

Thirdly, the approach to integrating health in regional planning is not systematic and seems to depend heavily on whether interventions are managed directly by the regional health authorities. This means that the health impacts or benefits of non-health investments are not considered by health experts.

These shortcomings call for a number of improvements including: more stable partnerships between regional planning, regional health authorities and other stakeholders; better communication and strategic coordination early in the planning process; and availability of operational, comprehensive and comparable targets to assess potential health gains of Structural Funds investments. It will also be crucial to capitalise on potential complementarity between some of the measures to institutionalise health impact assessment that are currently under consideration in Andalucía and initiatives to mainstream the assessment of health impacts of non-health investments co-financed by the Structural Funds. 

Background information

One of Spain’s largest and most well-known regions, Andalucía is one of the biggest recipients of EU Cohesion Policy funding in Europe, with over €8 billion in EU co-financing allocated for 2007-2013. The region is a long-standing recipient of Structural Funds financing, and well-experienced in the management and implementation of regional development programmes.

Covering over 87,000 km2, Andalucía is Spain’s second largest region (17.3% of the country’s surface) and one of the largest in Europe. It is located between the Mediterranean Sea and the Atlantic Ocean and boasts an 817 km-long shoreline. It is a peripheral, significantly rural region (about one-third of the population lives in rural areas) with substantial internal imbalances in terms of population density, economic structure and development levels.

Andalucía is Spain’s most populated region with 8.3 million inhabitants (2010), but it is less densely populated than the EU average. It has a relatively young population by both Spanish and EU averages: 16.25% of the population are under 15 and 14.75% are over 65.

Figure 1: Spanish regions, by Cohesion Policy status, 2007-2013

Source: DG Regional Policy – Inforegio


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

Population (inh., 2010)

8.3 m

Surface area (km2)

87,268

GDP per capita in EUR (PPS, 2008)

19,900 

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

80%

Cohesion Policy status

Convergence

Life expectancy at birth, male (2008)

76.9

Life expectancy at birth, female (2008)

82.9

Sources: Eurostat and Fifth report on economic, social and territorial cohesion

Andalucía’s economy is characterised by weak regional integration and productivity levels, above-average weight of the primary sector (agriculture, forestry, fisheries and mining) in total output and a relatively underdeveloped industrial sector by Spanish standards. Construction and tourism (Andalucía is among the country’s top destinations) account for a substantial share of the region’s economic activity.

Figure 2: GDP per capita in PPS (EU27 average = 100)

Source: Eurostat; GDP per capita in PPS is Gross Domestic Product in purchasing power standards.

In 2008, life expectancy at birth in Andalucía was 76.9 years for men and 82.9 years for women, which is slightly higher than the EU 27 average of 75.8 (men) and 82 (women).

In terms of overall development, however, Andalucía scored below the EU average on the EU version of the UN’s Human Development Index (HDI).[1] This index includes healthy life expectancy, household income, and educational attainment levels. Andalucía scored 47.8 out of 100 compared to an average value of 62 for EU regions.

 

 

Policy and institutional overview

Cohesion Policy

Andalucía is one of the eight Spanish regions receiving assistance from the Structural Funds under the Convergence objective during the current programming period (half of them with phasing-out status). It is also the largest recipient of EU financing in the country. The planning of Structural Funds use in the region is based upon a regional strategic framework document (Marco Estratégico Regional de Andalucía (MER-AN) 2007-2013), which is the region’s contribution to the National Strategic Reference Framework (NSRF).

Unlike for 2000-2006, when all strategic priorities were addressed in a Joint Operational Programme (Programa Operativo Integrado de Andalucía), Structural Funds interventions in the region for 2007-2013 are set out in two separate OPs, one for ERDF and one for ESF, which together represent about €8 billion in allocations.

Managing institutions

For the ERDF, the Managing Authority is the General Sub-directorate for the ERDF, located in the General Directorate for Community Funds of the Ministry of Economy and Finance (Ministerio de Economía y Hacienda). The intermediate body (organismo intermedio) for the region is the General Directorate for European Funds and Planning of the Regional Ministry of Economy, Innovation and Science (Consejería de Economía, Innovación y Ciencia de la Junta de Andalucía).[2]This intermediate body manages the regional OPs on behalf of the Managing Authority, and is in charge of programming, monitoring, evaluating and verifying interventions involving EU financial assistance within the competence realm of the regional government.[3]

For the ESF, the Managing Authority is the Management Unit of the Administrative Unit for the European Social Fund, within the national Ministry of Labour and Social Affairs. As for the ERDF, the intermediate body responsible for implementing the programmes in Andalucía is the General Directorate for European Funds and Planning of the Regional Ministry of Economy, Innovation and Science. Within this intermediate body there are separate departments for the ERDF and ESF programmes.

Health sector

 

Overview of institutions

Health and consumer protection competences are devolved to regions (Autonomous Communities) in Spain. In Andalucía, the Regional Ministry of Health is in charge of implementing health and consumer protection policies, planning health care and assistance, allocating resources, and managing, overseeing and evaluating healthcare services. Particularly relevant for this project is the existence within this ministry of a Secretariat-General for Public Health and Participation which comprises a technical advisor on Health Impact Assessment.    

The Regional Ministry for Health is responsible for a number of hospitals and first aid centres that are publicly-owned enterprises, as well as the Agency for the Evaluation of Healthcare Technologies, Andalucía’s Public Health School[4]and Andalucía’s Health Service. The latter is the main organ in the region’s public health system and is in charge of healthcare service provision, health protection and promotion, and preventive health care.

Healthcare in Andalucía: Main Figures[5]

9,797.66 M € Health budget (2010)

1,500 Primary care centres (387 Main PHC, 1,113 Local PHC)

44 Public hospitals (5 level I, 9 level II), 6 level III, 14 level IV, 10 proximity H)[6]

8 Transfusion centres

95,000 Healthcare professionals

 

Overview of public health policies and objectives

The overall strategy and main objectives and priorities for healthcare and public health in Andalucía are presented in the Andalusian Health Plan (Plan Andaluz de Salud). These plans extend through five-year periods. The most recent plan covers 2003-2008 (III Plan Andaluz de Salud); there have been delays for a plan for 2009 onwards to enter into force. The most up-to-date document currently available therefore is the Government Commitments for the IV Andalusian Health Plan (Compromisos de Gobierno para el IV Plan Andaluz de Salud). The commitments contained in this document, which are expected to become the priorities of the new plan, are the following:[7]

  1. Increase life expectancy in good health condition and improve overall living conditions
  2. Protect and promote public health to face the challenges from climate change and globalisation, environment- and food-related risks, and the global economic crisis
  3. Generate and develop the region’s health assets, and make them available to the Andalusian society
  4. Foster sustainable knowledge management and technologies to improve public health
  5. Ensure that the Andalusian public healthcare system “serves the citizenship”
  6. Reduce health-related social inequalities

Interviews with relevant health authorities carried out during the preparation of this case study suggest that increasing awareness of the health impact of public policies will be an overarching priority of the upcoming Andalusian Health Plan.

At the time of writing, the approval of a new Public Health Law (Ley de Salud Pública) for Andalucía is under discussion. The current legislative proposal seeks to “institutionalise” the carrying out of health impact assessments for all regional plans and programmes with a potentially significant impact on health. Moreover, the proposal states that all projects and interventions in the region, either public or private, should undergo this kind of assessment whenever they are deemed to have a potentially significant impact on health.

Health in the Structural Fund programmes

A review of the two Operational Programmes for Andalucía shows that the majority of references to and consideration of health occurs in relation to direct spending on healthcare; health infrastructure is the largest spending category within the social infrastructure priority.

At the same time, the impact of non-health investments on health gains is given some consideration in the strategic analysis of the region, and in some of the specific investment priorities.

OP for the European Regional Development Fund (ERDF)

In Andalucía’s ERDF OP, the main focus on health is within the context of health care/health services.

This focus is illustrated by the health-related statistics used to underpin the strategic analysis of the region (under the health and education heading):  no. of hospitals, no. of hospitals  per 10,000 inhabitants, no. of doctors per 1,000 inhabitants, and no. of hospital beds per 1,000 inhabitants.

The SWOT analysis presented in this OP does however include indicators measuring fatal and non-fatal accidents as a share of total population, which would measure effects of non-health investments. The environmental impact assessment of the OP links spending category 29, “Airports” to an operational indicator measuring the number of inhabitants “likely to be affected” by increased noise pollution. This assessment also links spending category 48, “Prevention, control and reduction of pollution” to an operational indicator measuring the estimated reduction in emissions of greenhouse gases.

Priority Axis 1 of Andalucía’s ERDF ROP, development of the knowledge economy, foresees a number of interventions whereby health-related services can be improved through ICT, including a digital health history project, innovative practices database, ambulance fleet management, and SMS- and MMS- based services.

Priority Axis 2 on employability, social inclusion and equal opportunities is justified as a strategic priority notably in the light of its contribution to economic, social and territorial cohesion and, more precisely, as a means to enhance access to health resources.    

Priority Axis 3, environment, nature, water resources and risk prevention, highlights the importance of adequate water, wastewater and waste management for public health, but it does not formally address causal paths nor does it propose any indicators that or targets that would capture the public health impact.

Most direct investment in health takes place under Priority Axis 6, social infrastructure. Here health-related infrastructure (code 76) is the largest single programmed spending category with EUR 93.5m. This amounts to 24.9% of assistance allocated to the axis and 1.37% of the total Structural Fund allocation in the region. The OP states that this investment is consistent with the regional plan to improve the quality and cohesion of the national healthcare system (Plan de Calidad para mejorar la calidad y cohesión del Sistema Nacional de Salud).

OP for the European Social Fund (ESF)

Andalucía’s ESF OP states that is has taken onboard a recommendation issued in the ex-ante evaluation concerning the need to consider occupational health and safety in its assessment of the regional situation. More precisely, it includes the incidence index (or índice de incidencia, which is defined as the number of work-related accidents per 1000 insured workers) as a strategic indicator. It also refers to the National Strategy on Occupational Health and Safety 2007-2011.   

In section 8 on complementarity with other funds, the ESF OP acknowledges “moderate linkages” in the field of public health with the Programme for the use of the European Fisheries Fund (EFF). These concern the funding of awareness-raising campaigns for equal opportunities for women and immigrants.

Related to this, the ESF Department Head at the intermediate body pointed out that Structural Funds planning in Andalucía for the current programming period has been particularly attentive to the public health dimension of social and economic inclusion. This includes occupational risk prevention, as well as the protection of particularly vulnerable social groups such as drug addicts, disabled persons or socially excluded persons.

This official also mentioned Structural Funds interventions to improve the qualification of regional health professionals and capitalise on new technologies to improve health care in Andalucía as noteworthy direct investments in health.

Tables 2 and 3 below summarise the key priorities and intervention areas of both OPs, as well as their correlation with the proposed briefing sheet topics. Whenever applicable, the tables also show how health is considered within each priority.

Tables 2 and 3: Overview of Andalucía’s OPs

OP for the European Social Fund Andalucía

MA: Management Unit of the Administrative Unit for the European Social Fund, Ministry of Labour and Social Affairs

Total EU allocation: € 1,155.76m

Priority Axis

Funds (€m)

Percent of total OP

Content of priority

Briefing Sheet topic(s)

Health considerations in the priority

Entrepreneurship promotion and improvement of the adaptability of workers, enterprises and entrepreneurs

200.56

5.29%

Self-employment and enterprise creation Lifelong learning at the workplace Improvement of work organisation techniques

Education and training

 

Index of work-related accidents per 1000 insured workers is associated to the axis

Promote employability, social inclusion and equal opportunities for men and women

489.34

19.18%

Modernisation of the labour market including the increase of participation rates Inclusion- and equality-oriented policies

Promotion of stakeholder cooperation

Employment

 

Contribution to equal opportunities through improved access to health resources

Increase and improvement of the human capital stock

400.53

29.92%

Education reform Vocational training Reduction of early school leave

Inclusion and participation

Support of research and innovation

Education and training

Institutional capacity

RTD

 

Promote transnational and interregional

 

51.52

29.02%

Cross-cutting

Institutional capacity

 

Technical assistance

13.80

10.24%

Cross-cutting

N/A

 

Total ESF OP

1,155.76

100%

 

 

 

OP for the European Regional Development Fund Andalucía

MA: General Subdirectorate for the ERDF, Ministry of Economy and Finance

Total EU allocation: € 6,843.93m

Priority Axis

Funds (€m)

Percent of total OP

Content of priority

Briefing Sheet topic(s)

Health considerations in the priority

Development of the knowledge economy (R&D, the information society, ICT)

361.78

5.29%

Research centres

Support of innovative SMEs

Public e-services (incl. health)

ICT infrastructure, e-commerce

ICT

RTD

Health-related services can be improved through ICT

Development and innovation of the private sector

1,312.84

19.18%

Support of SMEs: R&D and innovation, environment-friendly products and processes

RTD

 

Support to projects to prevent/minimise noise levels, luminous pollution and air pollution; support to projects for depollution of old mining sites

Environment, nature, water resources and risk prevention

2,047.77

29.92%

Infrastructure (waste and wastewater, water quality and supply)

Climate change mitigation and adaptation

Biodiversity protection 

Climate change

Infrastructure: water

Infrastructure: waste

Biodiversity

Acknowledges the importance of adequate water, wastewater and waste management for public health

Transport and energy

1,985.88

29.02%

Infrastructure Promotion of transport intermodality

RE development

Energy efficiency

Transport

Climate change

Energy

Seeks to encourage the purchase of “greener” vehicles and the use of less contaminating transport fuels

Local and urban sustainable development

700.82

10.24%

Urban and rural regeneration, tourism, preservation of cultural heritage

Urban and rural regeneration

Culture and heritage

 

Social infrastructure

388.19

5.67%

Health, education, childcare

Social infrastructure

 

Direct investment in health-related infrastructure is the largest single programmed spending under this priority

Technical assistance and strengthening of institutional capacity

46.66

0.68%

Cross-cutting

N/A

 

Total ERDF OP

6,843.93

100%

 

 

 



Integrating health in the programmes

This section covers the process and experience with integrating public health issues into the planning of the Structural Fund programmes in Andalucía, 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 health authority. A list of interviews conducted is contained in the References section of this report.

Andalucía has a good record of inter-ministerial cooperation in strategic planning. The Technical Advisor on health impact assessment of the Regional Ministry for Health talked of “close cooperation” between her Ministry and those for Environment, Education, Equality, and Social Affairs. This cooperation has translated into a number of joint strategies, plans and programmes including the Energy Sustainability Plan, Climate Change Mitigation Action Plan, and Disabilities Plan among others. This official observed, however, that this kind of cooperation is not systematic yet, and that regional health authorities still “find it hard” to mainstream the integration of public health considerations into the Structural Funds planning process. 

Consultation with health sector in the 2007-2013 programmes

Broad-based cooperation at the institutional level as well as with representatives of the main economic agents and the civil society is stressed in both of the OPs. Implemented in accordance with the partnership principle, this cooperation relates to analysis of the regional development context, and also strategic and financial planning.

Andalucía’s ERDF OP states that intermediate body in charge of implementing the programme has involved all other regional ministries including the one in charge of public health and health care. The ESF OP mentions that the intermediate body will be supported by a number of institutions and socioeconomic agents including Andalucía’s regional Health Service, the Servicio Andaluz de Salud. The exact content or scope of this cooperation is not disclosed in either programme.

Regional planning for the 2007-2013 period started with the updating of the interim assessment of Andalucía’s 2000-2006 Integrated Operational Programme (Programa Operativo Integrado), which resulted in a strategic document outlining the guiding principles for regional development. According to the Head of Planning and Coordination in the intermediate body, consultations on this process started in October 2005.

On the basis of the above-mentioned strategic document, Andalucía’s Economic Policy Commission[8]formally invited all regional ministries (including the Regional Ministry for Health) to submit their draft sectoral strategies for the following programming period as well as a first catalogue of measures to be integrated in the Operational Programmes. These consultations also benefited from the creation of a working group on the promotion of socioeconomic agents’ participation in regional planning that was created under the 2005 VI Agreement on Social Partnership in Andalucía (VI Acuerdo de Concertación Social en Andalucía).

Role of the health sector

The 2007-2013 programming period marked the first one for which health authorities were formally consulted in the development of the programmes. (Note: this is most likely related to the fact that 2007-2013 was the first programming period for which direct investment in health was possible according to the Cohesion Policy funding categories). In this sense, the regional health ministry contributed directly with proposals for direct health investments, and also acts as project proponent for certain types of projects, including health-related training.

According to the Technical Advisor on health impact assessment of the Regional Ministry for Health, the formal consultations on regional development planning and the preparation of the OPs were however limited in scope.

Further needs

Based on interviews conducted during the preparation of this case study, two main hindrances seem to exist with regard to the integration of health considerations into the Structural Fund programmes.

The first stems from the fact that wider public health is often considered only implicitly. “Since selected projects have to comply with regional, national and EU legal requirements, then their impact on health can only be positive, as these legal requirements support health”, so the reasoning goes. Under this approach, there is no assurance that major potential health impacts are not overlooked, nor are the details of the health gains captured and possibly optimised.

The second hindrance relates to the lack of a systematic approach to the integration of health issues. For example, according to a regional government representative, the impact on health of ESF-funded interventions “has only been taken into account for projects that were managed directly by the Regional Ministry for Health”.

Although promising measures in related areas are currently under consideration (see references to the Ley de Salud Publica and Health Plan in section 2), no specific plans or instruments are currently foreseen to systematise the assessment of health impacts of non-health investments co-financed by the Structural Funds.  

The ESF Department Head at the intermediate body pointed out that more flexible criteria for project selection and management may be required to better account for the singular features of health-relevant projects, particularly those with a large R&D or innovation component.

According to the ERDF Department Head at the intermediate body, Structural Funds have a role to play in addressing challenges to public health in Andalucía. He highlighted the far-reaching impacts of population ageing, social exclusion, immigration and a multiplicity of ongoing changes in living conditions, not the least climatic factors. The effective contribution of Structural Funds will however depend, according to him, on regional authorities’ ability to assess and maximise the impact on health of the wide range of non-health investments.

References

Print sources

Junta de Andalucía, Consejería de Economía y Hacienda: Criterios de Selección de Operaciones del Programa Operativo FSE de Andalucía 2007-2013, (ESF ROP Project selection criteria), undated.

Junta de Andalucía, Consejería de Economía y Hacienda: Programa Operativo FSE Andalucia 2007-2013 (ESF Regional Operational Programme), 2008.

Junta de Andalucía, Consejería de Economía y Hacienda: Programa Operativo FEDER de Andalucía 2007-2013 (ERDF ROP), 2007.

Ministerio de Economía y Hacienda: Criterios de Selección de Operaciones del Programa Operativo FEDER de Andalucía 2007-2013, (ERDF ROP Project selection criteria), undated.[9]

Junta de Andalucía, Consejería de Salud: Compromisos de Gobierno IV Plan Andaluz de Salud (Government Commitments for Andalucia’s IV Health Plan, unpublished).

Junta de Andalucía, Consejería de Salud: Healthy Andalusia (undated).

Health and Structural funds in 2007-2013: country and regional assessment, Country assessment Spain, EUREGIO III project for DG Sanco, 2009.

http://ec.europa.eu/health/health_structural_funds/used_for_health/index_en.htm

Interviews

Interviews with regional health authorities

Jacoba López Díaz, Asesora técnica de evaluación del impacto en salud, Junta de Andalucía, Consejería de Salud, Secretaria General de Salud Pública y Participación (Technical advisor on health impact assessment at the Regional Ministry for Health), 11-12 April 2011. 

Interviews with the intermediate body for Structural Funds programmes

Dirección General de Fondos Europeos y Planificación de la Consejería de Economía, Innovación y Ciencia de la Junta de Andalucía, (General Directorate for European Funds and Planning, Regional Ministry of Economy, Innovation and Science), all carried out 11-18 April 2011.

Adolfina Martínez,  Jefa del Servicio de Planificación y Coordinación (Head of Planning and Coordination)

Valentín Velázquez, Técnico responsable de evaluación (Assessment officer)

Mª Jesús Moreno, Jefa del Servicio del FSE (ESF Department Head)

Enrique Piña, Jefe del Servicio FEDER (ERDF Department Head)

Mª Luz Picado, Subdirectora General de Fondos Europeos y Planificación (Deputy Director General for European Funds and Planning)




[1]Cohesion Policy Report. Data for 2008.

[2]This Regional Ministry is referred to as Regional Ministry of Economy and Finance in the Operational Programmes. According to updates from interviewees in regional authorities, it has since evolved to becomethe Regional Ministry for Economy, Innovation and Science, which is the name that will be used throughout this report.

[3]Decreto134/2010 of April 13.

[4]At the time of writing, Andalucía’s Granada-based Public Health School is hosting the XI International Conference on Health Impact Assessment: http://www.hiainternationalconference.org/index.php/en

[5]Junta de Andalucía, Consejería de Salud: Healthy Andalusia, undated.

[6]Level I ≥1.000 beds, level II = 500 to 1,000 beds, level III = 250 to 500 beds, level IV ≤250 beds; Proximity = Hospitals in remote areas.

[7]Translation from Spanish by the case-study author

[8]This Commission is the body in charge of coordination for strategic planning at regional level.