Health in Italy in the 21st Century

FOREWORD

Rosy Bindi Minister of Health of Italy Roma, September 1999

This report provides the international community with an overall assessment of the state of health in Italy, as well as with the main developments of the Italian public health policy expected in the near future. It is intended as an important contribution towards the activities which, beginning with the 49th WHO Regional Committee in Florence, will be carried out in Europe with a view to defining health policies and strategies for the new century. This publication, which consists of two sections, illustrates the remarkable health achievements of Italy as regards both the control of diseases and their determinants, and the health care services. Overall, a clearly positive picture emerges, which is due not only to the environmental and cultural characteristics of Italy, but also to its health protection and care system which Italy intends to keep and indeed to improve in the interest of its citizens. The recent decisions taken in the framework of the reform of the National Health System in Italy intend to improve and strengthen the model of a universal health system based on equity and solidarity, which considers health as a fundamental human right irrespective of the economic, social and cultural conditions of each citizen. The new national health service guarantees, through its public resources, equal opportunities for accessing health services as well as homogenous and essential levels of health care throughout the country. Such a reorganization of the system has become necessary in order to meet new and growing demands for health within the framework of limited resources and with the understanding that equity in health is not only an ethical requirement, but also a rational and efficient way for allocating resources. We truly believe that health consumerism- does not lead to greater and better health care, but rather exhausts resources and increases inequity. Yet, given that the real challenge over the next years will be the provision of an extended health protection, it is necessary to bring about significant changes to the health care system through strengthening of prevention, rehabilitation and integration of the social and health dimensions, as well as the role of citizens and health professionals in promoting the process of change. This means, in essence, moving the focus of the policy from treating- to taking care- of the sick in a broader perspective, which is more consistent with the World Health Organization's definition of health as physical, psychological and social well-being. This is also the direction outlined in the 1998-2000 Italian National Health Plan (which is also included in the present report) that has been conceived as a true Solidarity Agreement

for Health-. Such an agreement commits institutions, professionals, citizens and their organizations, the research community and industries to taking on common responsibilities for achieving the health objectives agreed upon. We would like to share the spirit of this agreement with the other countries of Europe looking forward to the new century.

file://Q:\-COMMON\TRANSPRT\From%20Nicoletta%20to%20Dany\Ehi\itahfa21\forew ... 07-Jan-02

FOREWORD

J.E. Asvall WHO Regional Director for Europe

As we stand on the brink of the twenty-first century, we have a strong obligation to take action to improve the health of the 870 million people of the Region. The Health21 policy approved by the WHO Regional Committee for Europe in September 1998 provides the framework for accepting that challenge by applying the best strategies that have emerged from Europe's collective experience during the past ten to fifteen years. It is not a vision beyond our grasp it can be done. Experience has shown that countries with vastly differing political, social, economic and cultural conditions can develop and implement health for all policies designed to put health high on the agenda and when they do, they stand to gain from a fundamental change for the better. The major challenge for the 51 Member States of the European Region is to use the Health21 policy as an inspirational guide to update, as necessary, their own policies and targets. The commitments taken by the European member countries at the Third Ministerial Conference on Health and Environment held in London 16-18 June 1999 are an excellent example of what can be achieved when scientific evidence, innovative thinking and political leadership are put together within a coherent health policy framework to achieve common goals. The Health in Italy in the 21st century- report, prepared by the Italian Government with the assistance of the Rome Office of the WHO European Centre for Environment and Health, is an important step towards the implementation of the Health21 policy and principles. It underlines the achievements of the past years, relates them with the Health21 goals, and sets the direction for future health policy developments as outlined in the 1998-2000 Italian National Health Plan. The document provides scientifically sound data against which future assessments can be measured. I would like to use this opportunity to commend the Italian government for undertaking this work which transforms the vision of Health21 into a practical and sustainable reality. This, I am sure, will encourage other Member States to do the same.

ACKNOWLEDGEMENTS The Report Health in Italy in the 21st Century has been produced jointly by the Ministry of Health of Italy and the WHO European Centre for Environment and Health (WHO/ECEH) thanks to the work of two teams (Ministry of Health and WHO/ECEH) and to the additional support and valuable contributions of a large number of other organizations and experts. Teams for the preparation of the Report Health in Italy in the 21st Century Overall coordination and supervision: Roberto Bertollini (WHO/ECEH) and Vittorio Silano (Ministry of Health, Repubblica Italiana) Scientific/technical/editorial work: WHO/ECEH Team Nicoletta Di Tanno, Michele Faberi, Manuela Gallitto, Daniela Giannuzzo, Philip Gorman, Lucilla Magherini, Maria Teresa Marchetti, Francesco Mitis, Candida Sansone, Manuela Zingales. Ministry of Health of Italy Team Francesco Cicogna, Gianfranco Costanzo, Gaetano Della Gatta, Katia Demofonti, Angelo De Siena, Luisa Gabrielli, Stefano Moriconi, Fabiana Leoni, Alessandra Pappagallo.

Several Department and Service Directors of the Ministry of Health of Italy (Claudio Calvaruso - Director General, Studies and Documentation; Nerina Dirindin - Director General, Health Planning; Fabrizio Oleari Director General, Prevention, and Giovanni Zotta - Director General, Institutions Control) have kindly provided highly appreciated advice, data and information, when reviewing the Report. Similary, enlightening contributions have been received by Antonio Moccaldi, Director General, National Institute for Prevention and Safety at the Workplace, and Francesco Taroni, Director General, National Agency for Regional Health Services as well as by members of their staff. Information, advice, data and support was provided throughout the preparation of this report by the National Institute of Health (ISS). Particular thanks go to Giuseppe Benagiano, Director, National Institute of Health, and to many of his staff: Riccardo Capocaccia, Marco De Sanctis, Massimo Giuliani, Donato Greco, Alfonso Mele, Giovanni Rezza, Stefania Salmaso and Barbara Suligoi. The Italian National Statistics Institute generously shared information and data. Thanks to Viviana Egidi, Director for Population and Territory, and her co-workers Giovanna Boccuzzo and Vittoria Buratta, for the collaboration. Claudia Galassi, CDS Bologna, gave a significant input and scientific contribution to the report, and Giuseppe Costa, Director of the Public Health Laboratory, ASL 5 Piemonte Region, has made available his pioneering experience and work on inequalities and health. Riccardo Poli, member of the Higher Health Council of Italy, has contributed the Chapter on "Bioethics in human health"; Edoardo Missoni, Ministry of Foreign Affairs, the Section on Italian Development Co-operation and Raffaele Tamiozzo, Head of the Legal Office, Ministry of Health, the Chapter on "Italian Health Service Reform". Eva Buiatti, CSPO, Florence; Francesco Forastiere, Lazio Region Epidemiology Unit; Colin Soskolne, University of Alberta (Canada) and Benedetto Terracini, University of Turin, have reviewed the first draft of the text and provided very useful comments and suggestions. A number of other experts, including Piero Borgia and Marina Davoli, Lazio Region Epidemiology Unit; Ernesto Caffo, Telefono Azzurro; Bruno Dalla Piccola, Second University of Rome (Tor Vergata); Anna FerroLuzzi and Luisa Pizzoferrato, National Institute of Nutrition; Luigi Greco, University of Naples; Paola Pula Leggio, Ministry of Health; Pierpaolo Mastroiacovo, Catholic University of Rome and Giorgio Tamburlini, Istituto per l'Infanzia Burlo Garofalo, Trieste, have provided valuable data, information and advice in their

areas of expertise.

TABLE OF CONTENTS

FOREWORD by Rosy Bindi (Minister of Health of Italy) FOREWORD by J. E. Asvall (WHO Regional Director for Europe) ACKNOWLEDGEMENTS

PART I Achievements and challenges in the European context

I - International solidarity for health and development II - Italy as an ageing society III - A healthy start in life IV - Non-communicable diseases V - Communicable diseases VI - External causes of mortality and disability VII - Health determinants: nutrition, lifestyle, physical environment and human settlements VIII - Equity in health IX - Bioethics in human health X - The Italian National Health Service XI - Human resources and research for health

PART II The way forward

XII - Nation wide solidarity agreement XIII - Priority objectives for health XIV - Change-promoting policies and strategies XV - Italian health service reform XVI - Methods and data sources

ANNEXES REFERENCES

CHAPTER I

INTERNATIONAL SOLIDARITY FOR HEALTH AND DEVELOPMENT CONTENTS 1. INEQUALITIES IN HEALTH WORLD-WIDE .......................................... 4 2. INEQUALITIES IN HEALTH IN THE WHO EUROPEAN REGION............. 5 3. ITALIAN GOVERNMENT CONTRIBUTIONS TO INTERNATIONAL SOLIDARITY ..................................................................................... 8 3.1 International Organizations........................................................ 8 3.2 European Union ........................................................................ 10 3.3 Italian development co-operation .............................................. 11 4. CITIZEN DIRECT PARTICIPATION TO HUMANITARIAN ASSISTANCE .................................................................................... 14

4 - International solidarity for health and development

This major economic gap and the consequent increase in prevalent poverty is reflected in the distribution and time trend of major health indicators. Inequalities in life expectancy at birth and mortality rates1 are very significant world-wide and indeed much more significant than in the European Region (WHO, 1999a). Many countries are facing several problems from infectious diseases (such as HIV/AIDS), while chronic non communicable diseases, such as heart disease, cancer, diabetes and other “lifestyle” related-conditions (see also Chapter II) are on the increase. Refugees represent an especially vulnerable population, and their number increased markedly world-wide during 1985-1990, from 10.5 million to 14.9 million, accounting for 12.4% of the world’s migrant stock in 1990. By early 1996, the total number of refugees stood at 13.2 million. Recent crises in different parts of the world, including Europe, are again responsible for increase in this number.

1. INEQUALITIES IN HEALTH WORLDWIDE A recent review by the United Nations Conference on Trade and Development (UNCTAD) suggests that, since the early 1980s, the global economy has been experiencing rising inequalities (Table I.1) and that income gaps among countries have continued to widen. In 1965, the average per capita income of the G7 industrialised countries was 20 times that of the world’s poorest seven countries; by 1995, it was about 50 times greater. Although a number of developing countries have been growing faster than the developed market economies, growth rates have not been fast enough to narrow the absolute per capita income gap. One major constraint inhibiting further economic growth and international macroeconomic stability has been the debt burden of the developing countries (WHO, 1998a).

Table I.1: Growth of GDP and GDP per capitaa. GROWTH OF GDP (ANNUAL PERCENTAGE CHANGE)

GDP PER CAPITA (USD)

1981-1990

1991-1996

1980

1996

1997

World

3.1

3.3

4 883

5 966

6 123

Developed market economies

2.8

1.7

16 547

21 995

22 497

Economies in transitionb

2.0

– 6.4

5 464

4 012

4 062

Developing countries

3.8

5.8

2 102

3 147

3 282

2.4

3.5

1 097

1 132

1 159

of which LDCs

c

a b c

On the basis of purchasing power parity. Including the former German Democratic Republic until 1990. Least Developed Countries.

Source: WHO, 1998a.

Life Expectancy: the average number of years an individual of a given age is expected to live if current mortality rates continue to apply. A statistical abstraction based on existing, age-specific death rates (Last J., 1988). Mortality rate: proportion of a population that dies during a specified period. It is obtained dividing the number of persons dying during the period by the size of the population, usually estimated as the mid-year population (Last J., 1988).

1

International solidarity for health and development - 5

2. INEQUALITIES IN HEALTH IN THE WHO EUROPEAN REGION The WHO European Region includes some of the richest countries in the world as well as others which are extremely poor; a large, group of countries is now less well-off than ten years ago. In 1995, the per capita Gross Domestic Product in Europe (GDP) ranged from 943 USD to over 34 004 USD (Figure I.1).

According to the UNDP Human Development Report (UNDP, 1997), a number of countries has seen a great economic decline in the past decade. Poverty has spread and about 120 million people in Europe live below the poverty line of 4 USD a day. The economic upheavals and the wars in the Countries of Central and Eastern Europe (CCEE) and Newly Independent States (NIS) during the 1990s have increased the health

Countries

Figure I.1: GDP per person, expressed at purchasing-power parity, in the WHO European Region+ - 1995.

US Dollars +

Source: WHO, 1999c.

6 - International solidarity for health and development

status gap between countries in the Region, as reflected in the wide range of variations in many basic health indicators (WHO, 1999b). Total mortality rates and life expectancy are two powerful indicators of the overall health status of the European population and are useful descriptors of the inequalities among countries. The average life expectancy in the WHO European Region has declined for the first time since the World War II; starting from 1990, the average life expectancy in the NIS decreased for

both sexes from 73.1 years in 1991 to 72.4 in 1994. Female life expectancy is higher in all countries: on average, it is 76.68 years as compared to 68.07 for males (Figure I.2). Long-term trends show a continuous improvement of life expectancy in Western Europe (although the improvement rate varies significantly among individual countries). Figures indicate a stabilisation in the CCEE and a decrease in the NIS. In this situation, the gap in life expectancy between Eastern and Western European countries that started about three decades ago is steadily growing (Figure I.3).

Countries

Figure I.2: Life expectancy at birth in the WHO European Region for females and males – 1994.

Life expectancy (yrs) Source: WHO, 1999c.

International solidarity for health and development - 7

Life expectancy (yrs)

Figure I.3: Life Expectancy at birth for both sexes combined in subregional groups of countries in the WHO European Region. Time trend.

Source: WHO, 1999c.

TARGET 1 - HEALTH21 By the year 2020, the present gap in health status between Member States of the European Region should be reduced by at least one third. In particular: 1.1 the gap in life expectancy between the third of European countries with the highest and the third of countries with the lowest life expectancy levels should be reduced by at least 30%; 1.2 the range of values for major indicators of morbidity, disability and mortality among groups of countries should be reduced through accelerated improvement of the situation in those that are disadvantaged.

Calendar year

Estimates of life expectancy in Europe for 1997 show that the difference between the third of those countries with the highest (average 78.2 years) and the third with the lowest (average 68.7 years) was 9.45 years (WHO, 1998a). In order to meet the Health 21 target and assuming the 1997 values of the highest tertile as a reference, this gap should be reduced to 6.61 years by 2020. Life expectancy projections for the year 2025 indicate that the highest tertile of countries will move to an average of 80.2 years and the lowest to 74.3 years (WHO, 1998a). Under this hypothesis, the gap between the highest and the lowest tertile will be 6.5 years, thus making the above-mentioned target achievable. The range of differences of major indicators of mortality and morbidity in the European countries mirrors the trend observed for total mortality (WHO, 1999b).

8 - International solidarity for health and development

3. ITALIAN GOVERNMENT CONTRIBUTIONS TO INTERNATIONAL SOLIDARITY

operation in health and social development with many developing countries.

In order to promote global health, poverty in the poorest countries of the world, as well as the pockets of poverty which exist within developed countries, should be significantly reduced. Policies directed at improving health and ensuring equity are the keys to economic growth and poverty reduction. Sharing health and medical knowledge, expertise and experience on a global scale is another powerful way of promoting equity in health. Humanitarian relief must be provided when needed. Industrialized countries, such as Italy, have a vital role to play in helping to solve global health problems. In the context of the 1998 World Health Declaration and its commitment to the highest attainable level of health for all, existing differences in economic, social and health conditions throughout the world represent a serious threat upon human rights. Italy considers health to be a fundamental human right, and the progressive growth of large inequalities in health conditions and quality of life within and among different areas of the world to be unacceptable. The promotion of equity in health is, therefore, a priority of the Italian Government not only at national level, but also at European level and indeed world-wide. Italy is an active member of the United Nations and its subsidiary and specialised Bodies, as well as a member of several other intergovernmental Organizations such as the Council of Europe (CE) and the Organization for Economic Cooperation and Development (OECD). The efforts of Italy to alleviate the suffering of the poor and promote equity in health, in addition to social and economic developments, are also directed by the European Union through funding allocated for international co-operation and humanitarian assistance. Lastly, Italy has also established significant levels of bilateral co-

3.1 International Organizations Italy actively supports large numbers of UN Programmes, subsidiary Bodies, specialised Agencies and related autonomous Organizations. In this respect, the UN System is regarded by Italy as an essential component of its foreign policy, particularly in the area of peacekeeping, humanitarian assistance and solidarity for health promotion and social development. Italy is currently the fifth largest contributor to the UN regular budget, allocating in 1998 56.9 million USD, roughly corresponding to 5.4% of the total UN budget. An additional contribution of approximately 64 million USD has been provided by Italy through the participation in UN peace keeping operations in countries such as Lebanon, Kuwait, ExYugoslavia and Albania. Additional funding is provided by the Italian Government to the UN System through regular budget contributions to the specialised Agencies and other Organizations (for some figures see Table I.2) as well as to the UN International Court of Justice (5.2 million USD per year). In addition to regular contributions, in 1998 the Italian Government allocated about 80 million USD as voluntary contributions to UN Programmes, Organizations and Funds active in the areas of humanitarian assistance, economic development and health promotion (see Table I.3 for details). Some of these also benefit from earmarked funds to support specific projects in developing countries. In this framework, Italy considers the support it gives to WHO as one of its priorities, and significantly contributes to its “extrabudgetary funds”. One major Division of the WHO European Centre for Environment and Health is based in Rome and many WHO Collaborating Centres2 operate in Italy, often supported by the competent Region or Self-governed3 Provincial

2 A WHO Collaborating Centre is defined as an institution designated by the Director General to form part of an international collaborative network carrying out activities in support of the Organization’s programme at all levels. This definition does not include all other Institutions collaborating with WHO under other arrangements. 3 Synonym of "autonomous" also used throughout the present report.

International solidarity for health and development - 9

Table I.2: Italian Regular Budget Contributions to UN Specialised Agencies – 1998. UN AGENCY

CONTRIBUTION (MILLION USD)

IARC - (International Agency for Research on Cancer) ILO - (International Labour Organization) FAO - (Food and Agriculture Organization) WHO - (World Health Organization)

Authorities (Annex 1). It should also be mentioned that these provide support to specific WHO programmes (both HQ and EURO). Italy is also an important contributor to several other International Organizations. Italy is a founder country of the OECD and participates in the initiatives of this Organization to promote social welfare by co-ordinating the economic policies of Member States and to stimulate and harmonize Member States efforts towards developing countries. Of all the current 29 member countries, it is the fifth largest financial contributor after the USA, Japan, Germany and France. In 1997, the total Italian contribution to the OECD was approximately 14 million USD.

1.3 12.0 17.9 21.3

Similar considerations apply to Italy’s role in the CE, an intergovernmental Organization whose main objectives in the social field include the protection of human rights of all populations and minority groups as well as the search for solutions to social problems, such as xenophobia, intolerance, environment protection, bioethics, AIDS and drug abuse. Italy is one of the founder countries of the CE, which, at present, includes 41 nations Europe-wide. The main activities of the CE supported by Italy include health issues such as: • European Pharmacopoeia. • Blood Transfusion: ethics and safety. • Organ transplants.

Table I.3. Voluntary contributions of Italy to UN Programmes and Organizations – 1998. UN COMPONENT

ECEH (WHO European Centre for Environment and Health) FAO (Food and Agricultural Organization) CRC (International Committee of the Red Cross) IFAD (International Fund for Agricultural Development) ILO (International Labour Organization) UN/DESA (Department for Development Support) UNDCP (UN Drugs Control Programme) UNDP (UN Development Programme) UNETPSA (UN Educational and Training Programme for Southern Africa) UNFPA (UN Population Fund) UNHCR (UN High Commissioner for Refugees) UNICEF (UN International Children Fund) UNIDO (UN Industrial Development Organization) UNV (UN Volunteers) WFP (World Food Programme) WHO (World Health Organization)

CONTRIBUTION (MILLION USD)

1.5 8.6 3.7 1.1 4.8 5.7 8.6 10.8 1.1 1.4 6.9 6.8 2.3 0.6 4.6 3.7

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• Cooperation against drug dependence (Pompidou Group). • AIDS. • Youth-related problems. • Human health care services. • Consumer health protection. The Italian financial contribution to the CE in 1998 was about 21.6 million USD. 3.2 European Union Italy is a founder country of the European Economic Community (EEC) which, in 1993, became the European Union (EU). The European Union has a very active role not only in ensuring a high level of protection of health, but also in carrying out interventions in supporting the economic and social development of non-EU members, as well as in providing humanitarian and technical assistance. The fight against poverty is an essential component of EU cooperation for development; in 1998, the European Parliament, in fact, expressed support for a debt reduction in favour of countries in which poverty is a major issue. Proof of the commitment of the European Union in this area lies in its budget of 200 million USD allocated, for the years 2000-2006, to the enlargement of the Union to include Central and Eastern Europe. The European Union has signed cooperation agreements with several Mediterranean and Middle-Eastern countries (i.e. Algeria, Morocco, Tunisia, Egypt, Jordan, Syrian Arab Republic, Lebanon and Israel), and these have been in force since 1978. The economic cooperation and technical assistance provided by the European Union has also been extended to African (A), Caribbean (C) and Pacific (P) countries through the Lomé Convention. The fourth ACP-EEC Convention was signed at Lomé (Togo) by the EEC and its Member States, as well as by 69 ACP countries. It has a duration of 10 years, starting from 1 March 1990, and a financial protocol which is renewable every 5 years. This Convention provides for industrial cooperation (e.g. an ad hoc Centre has been set

up in Brussels), agricultural and rural development (e.g. an ad hoc technical Centre has been set up in Washington), as well as commercial and financial cooperations. In 1998, in compliance with article 255 of the 4th Lomé Convention, the EU adopted two programmes in favour of repatriated refugees and evacuees from Liberia and Guinea, with a budget of about 2.4 million USD. Since this convention entered into force, 75 similar programmes have been carried out with a global expenditure of about 82 million USD. In addition, under the provisions of article 133 of the Amsterdam Treaty, the Council has extended the System of General Preferences to all countries in need, regardless of whether they signed the Lomè Convention or not. In 1998, EU health cooperation with developing countries received special attention and was allocated a budget of about 248 million USD for priority sectors such as: • disease prevention; • human resource development; • health system organization; • coordination with other donors. In the same year, the total amount of food products donated by the EU to the World Food Programme (WFP) reached approximately 93 million USD. Resources allocated in the EU 1998 budget for food aid and food safety in favour of developing countries amounted to around 495 million USD, almost 385 million of which were used to purchase food products and to support food safety, and 110 million USD for logistic expenditures. In 1998, the EU also allocated 26.5 million USD to promote investments of mutual interest and to establish joint enterprises with non-EU country entrepreneurs (EC Investment Partners Instrument). Lastly, in 1998, within the framework of Regulation (CE) 2258/96 concerning rehabilitation and reconstruction in developing countries, the EU invested some 68 million USD, 49 of which were for ACP countries. European Community humanitarian assistance is provided, in particular, by the Euro-

International solidarity for health and development - 11

pean Community Humanitarian Office (ECHO). In 1998, the European Commission appropriated through ECHO the sum of 547 million USD for humanitarian relief, mostly consisting of interventions for health, food, rehabilitation and reconstruction (Table I.4). In financial terms; Bosnia and Herzegovina and the African Region of Great Lakes were the main areas of EU humanitarian intervention in 1998. If this budget is considered together with the resources provided by each Member State, it becomes clear that in 1998 the European Union was the most important donor for humanitarian relief world-wide. In 1999, the European Union reacted very promptly to the crisis in Kosovo both through ECHO and individual emergency plans. Expected support from ECHO in 1999 is in the order of 184 million USD. The financial involvement of the European Union in all of the above-mentioned activities constitutes a considerable part of the yearly budget that consists of: • customs duties; • agricultural drawings collected on products imported from third countries; • a fraction of the VAT applied on goods and services of the entire Union; • a fraction of the GDP of each country. Since Italy is one of the largest EU countries, on the basis of the above-mentioned mechanisms of

budget formation, it is also one of the main contributors to EU activities. 3.3 Italian development cooperation4 A process to re-define Italian strategies for development co-operation in health was undertaken in 1998, taking into account the modified international scenario and the experience gained in the field, in order to achieve a more effective synergy both with other international partners and with the Italian National Health System (INHS). In addition to humanitarian activities and response to natural catastrophes, the Italian cooperation managed more than 100 health programmes in 47 countries in 1998, with a global disbursement of around 37 million USD. Bilateral, multilateral and multi-bilateral net disbursements for health in the triennium 19961998 (Table I.5) and distribution by world Regions in 1998 (Table I.6) are shown below. Up to June 1999, Italy reacted to the Kosovo crisis by appropriating about 60 million USD for assisting refugees, hosting families and other interventions; an additional budget of about 40 million USD has been appropriated for the second stage of the intervention in Albania. In order to carry out the above-mentioned activities, the Italian Ministry of Foreign Affairs works in close liaison with the Italian Ministry of Health and with a number of other public Institutions, such as the National Institute of Health, the National Insti-

Table I.4: Humanitarian Assistance Provided by ECHO in various Geographical Areas of the World. GEOGRAPHICAL AREA

WHO European Region Mediterranean Countries and Middle East Asia Latin America ACP Countries

CONTRIBUTION (MILLION USD)

166.0 44.3 63.0 49.9 160.8

4 According to the 1998 OECD Report on Development Cooperation, the total disbursement in 1997 was equal to about 1 300 million USD which was devoted to a number of activities including education, health and population, production, debt relief, social and economic infrastructures and emergency aids.

12 - International solidarity for health and development

tute of Nutrition, Universities, the Health Care Institutes of a Scientific Character (IRCCSs), the Local Health Authorities and Local Health Agencies, as well as a significant number of Non-Governmental Organizations (NGOs). 3.3.1 Support to National Health Systems Support to National Health Systems and their development is the basic strategy of the Italian cooperation with developing countries in the health sector. In this framework, Italy recognizes the need for a strong coordination among donors and International Organizations (EU, WHO, UNICEF and other UN organizations, World Bank and other bilateral agencies) in supporting National Institutions. In Ethiopia, for example, Italy contributed to launch the National Health System Development Programme on the basis of a sectorwide approach which overcomes the traditional project-based approach, promoting direct support of national policies and coordinated investment plans amongst different donor countries. In a sim-

ilar way, the Italian cooperation co-ordinated the health planning of and technical assistance to the Palestinian Ministry of Health in 1998. A similar approach has been followed in Mozambique, in Eritrea and in Angola. Italy is the main donor country in Uganda, where it also promotes the integration between Governmental and private “no profit” services, with the aim to improve health care quality and accessibility, as well as to optimise the available resources. 3.3.2 Support to Local Health Systems Interventions in the health sector are mostly targeted to administratively and geographically well defined areas, such as districts, departments and provinces. These initiatives aim to promote decentralisation and implement at local level the National Health Plans, with the objective of improving the quality and availability of health care, as well as facilitating community participation in the promotion and management of health care systems. Good examples of this approach can be found in

Table I.5: Italian Co-operation to Development in the health sector: net disbursements by channel - 1996-1998. CHANNEL

1996 (MILLION USD)

1997 (MILLION USD)

1998 (MILLION USD)

38.6 8.6 15.5 62.7

41.0 2.4 3.4 46.8

25.9 4.3 6.9 37.1

Bilateral Multilateral Multi-bilateral TOTAL

Source: Italian Ministry of Foreign Affairs, 1999.

Table I.6: Italian Cooperation to Development in the health sector: net disbursements by world Region - 1998. WORLD REGION

Central Africa Southern Africa Mediterranean and Middle East Latin America Asia Southern and Eastern Europe Not assigned TOTAL Source: Italian Ministry of Foreign Affairs, 1999.

(MILLION USD)

3.7 11.8 4.1 2.5 7.1 5.2 2.7 37.1

International solidarity for health and development - 13

Angola, Uganda, Mozambique, Zimbabwe, Ethiopia, Egypt, Bolivia, Jamaica and China. 3.3.3 Development of information systems and epidemiological surveillance In Albania, Angola, Mozambique, Palestine and Swaziland, Italy is helping the building up specific information systems whose role is essential to health planning, in addition to running public health and environmental laboratories. Similar projects are currently in progress in some provinces of Zimbabwe and are also planned in South Africa in 1999, where Italy supports the development and implementation of a geographical information network. 3.3.4 Promotion of National Pharmaceutical Systems and essential drugs Actions for up-grading and strengthening the National Pharmaceutical Systems have been carried out mainly in collaboration with WHO. Bilateral actions aimed at ensuring the local production and distribution of essential drugs as well as supporting local stock management are under way in Morocco and Burkina Faso. 3.3.5 Promotion of health infrastructure and sustainable biomedical technologies Refurbishing existing health infrastructure and adapting them to users’ needs has been the goal of the Italian cooperation’s activity in Lebanon, Uganda, Egypt and Syria. The Italian co-operation gives great importance to the environmental and cultural impact as well as its technological appropriateness. In Bolivia, for example, it chose to refurbish an old hospital rather than build a brand new one. New health care structures have been built in some countries (e.g. Eritrea and Palestine). A programme aimed at updating available health technologies and organising the National maintenance system was started in Macedonia in 1998. A similar Programme has been in place for many years in Mozambique. In Tunisia and Algeria, the Italian co-operation has contributed to the re-

organization of second level health care services and to the implementation of computerized management of medical equipment, supply and maintenance. Finally, in Morocco, Italy provided financial support to the “Pasteur Institute” in Tangiers for parasitic infection research. 3.3.6 Primary health care Primary health care remains for the Italian cooperation an essential integrated strategy. The main areas of intervention are: • Control of communicable diseases: Italy supports the inclusion in National Health Plans and local systems of integrated activities for, among others, the prevention and control of malaria, tuberculosis, leprosy and AIDS. Through WHO, the Italian Cooperation takes part in poliomyelitis and dracunculiasis infection eradication campaigns in Africa. In Uganda, Ethiopia, Eritrea, Pakistan and the Philippines the fight against the resurgence of tuberculosis and its association with AIDS has been supported in compliance with WHO strategies. As far as malaria is concerned, Italy is supporting activities mainly through several Italian research Institutes working in African countries (e.g. Burkina Faso, Madagascar, Ethiopia and Eritrea). In 1998, the scientific cooperation agreement signed by Italy and the USA included in its agenda the fight against malaria in South-Saharan Africa. Furthermore, Italy endorsed the recommendation to include the strengthening of global parasitic infection control in the 1998 G8 agenda. • Family and Reproductive health: gender approach. Italy collaborates with WHO in defining and implementing strategies and policies in the field of Reproductive health and Nutrition. Specific activities in this area have been organically integrated in primary health care actions in Africa, Asia and Latin America. Women’s health promotion, with special regard to the most vulnerable groups (e.g. adolescents and single parent families) is particularly relevant in these programmes. • Disability prevention and rehabilitation. In Mozambique, Italy supports the de-institutionalisation and socio-economic integration of mentally handicapped people, by also providing techni-

14 - International solidarity for health and development

cal assistance, at national level, in the development of sectoral policies. In Uganda and Eritrea, the Italian co-operation supports the establishment of orthopaedic workshops and the training of physical therapists. In India, therapy and rehabilitation for people with spinal injuries, in addition to community based experiences, are being provided through the Italian cooperation. 3.3.7 Health promotion in the field of multisectoral programmes Often, the Italian co-operation promotes health actions within the framework of wider multi-sector initiatives. This is the case of the Local Human Development Programmes in Mozambique, Central America, Cuba, the Dominican Republic and Tunisia, as well as of the “Atlas Project” in Bosnia, implemented by UNOPS with a significant WHO input, on the basis of Italian financial support. Similarly, in the context of European initiatives for Somalia, Italy supports several health actions with the participation of Italian NGOs. In Somalia, Eritrea and Ethiopia, Italy participates with other countries in promoting the IGAD Forum: in this context Italy contributes, through WHO, to health actions to benefit nomadic and border populations. In some cases, health activities play a relevant role in the context of more complex international initiatives. In the peace process in the Middle East, Italy spearheads the public health initiative of the Refugees Working Group. 3.3.8 Development of human resources Training is an integral component of all the Italian co-operation initiatives. It is delivered locally and includes the updating and up-grading of local capacities in the framework of health systems reforms. Residential training courses are also organised in Italy, with fellowships enabling the participation of developing countries’ health personnel in training programmes within Italian health Institutions. In some countries (such as Jordan, Mozambique, Eritrea and Egypt), Italy supports local training Institutions and, in some other cases, such as Burkina Faso

and Madagascar, local applied research and capacity building. 3.3.9 Other activities Other institutional activities are carried out by the Italian Ministry of Health through specific agreements usually negotiated with non-EU countries and countries currently in the process of joining the European Union. These agreements, as a rule, make provision for the organization of training courses for health professionals, the establishment of scientific exchanges, health systems information exchanges, as well as facilitating of health co-operation actions by means of technical equipment delivery and support to hospital structures. Italy also co-operates with some of these countries through the EU Programme “PHARE” for the legislation alignment to the Community “acquis”, particularly in the field of phytosanitary and veterinary health, environmental pollution, the safeguarding of biodiversity and health and safety at work. Lastly, mention should be made of what is termed “decentralized cooperation” carried out by several Italian Regions, Autonomous Provinces and local Institutions, mostly with humanitarian objectives. This approach aims to strengthen cooperation and exchange among the local communities of donor and recipient countries, thus mobilizing additional substantial resources for development policies. This cooperation has also made it possible for a number of sick children and adults to undergo advanced medical treatments in Italian hospitals. 4. CITIZEN DIRECT PARTICIPATION HUMANITARIAN ASSISTANCE

TO

Innumerable cases and interventions witness the generosity of Italian citizens and their NGOs, as well as their invaluable contributions to international solidarity. A very recent example of this irreplaceable role is provided by the voluntary contributions in 1999 of more than 50 million USD to the “Rainbow Mission”, organized by the Italian Government, and of about 9 million USD to UNHCR to alleviate the Kosovo crisis.

CHAPTER II

ITALY AS AN AGEING SOCIETY

CONTENTS 1. AGE STRUCTURE OF THE ITALIAN POPULATION............................... 16 1.1 Present situation ........................................................................ 16 1.2 Future trends ............................................................................. 16

2 FACTORS UNDERLYING AGEING ...................................................... 17 2.1 Increased longevity and disability-free ageing............................. 17 2.2 Reduced natality ........................................................................ 21

16 - Italy as an ageing Society

1. AGE STRUCTURE OF THE ITALIAN POPULATION The proportion of the Italian population aged over 65 years is increasing very quickly and will continue to do so in the future. Although this development is undoubtedly an indicator of successful health and social policies in Italy, it also poses new challenges.

"elderly index", Italy is the "oldest" country in Europe (Table II.1). In Italy, there are marked geographical differences concerning the longevity of the population: in the North, the elderly index is twice as much as that of the South (Table II.2). The Liguria Region has the highest percentage of elderly people. 1.2 Future trends

1.1 Present situation In the WHO European Region, Italy has the smallest proportion of people aged 14 years or less (Figure II.1) and is second only to Sweden as regards the proportion of people aged 65 years or more (Figure II.2). According to the

Countries

Figure II.1: Population aged 0-14 in the WHO European Region - 1994.

Percentage Source: WHO, 1999c.

In Italy, the percentage of population aged 65 years or above was 9.5% in 1961 compared to 16.8% in 1996. Among people over 65 years, there is a greater and progressively increasing percentage of women, i.e. from 57.7% in 1961 to 60.0% in 1996.

Italy as an ageing Society - 17

Countries

Figure II.2: Population aged 65 years or more in the WHO European Region - 1995.

Percentage Source: WHO, 1999c.

A highly significant increase in the proportion of people over 65 years is expected to occur within the next 20 years: the most rapidly growing population in most countries will be those aged 80 years and above. At the end of the next 30 years, the average European proportion of people over 80 years, calculated as a share of the over-65 population, will increase from 22% to over 30%. Over the next 50 years the estimates of the proportion of population aged between 64 and 85 years and of that above 85 years in Italy are shown for women in Figure II.3a and for men in Figure II.3b (based on ISTAT 1997a).

2. FACTORS UNDERLYING AGEING The ageing of the Italian population results from two main factors: increased longevity and reduced natality. 2.1 Increased longevity and disability-free ageing A considerable increase in life expectancy at birth has been occurring both in Italy and in the European Union since 1970. Data are shown in Figure II.4a for women and in Figure II.4b for men.

18 - Italy as an ageing Society

Table II.1: Elderly population and index in some European countries - 1995.

COUNTRY

Sweden Italy Norway United Kingdom Greece Germany France** Belgium* Spain Denmark Austria Switzerland** Portugal Finland Luxembourg Netherlands Ireland** Iceland

POPULATION OVER 65 YEARS

ELDERLY INDEXa)

(%)

(%)

17.46 16.62 15.94 15.74 15.58 15.47 15.34 15.31 15.27 15.26 15.14 14.65 14.56 14.21 13.99 13.24 11.40 11.22

92.63 111.67 81.79 81.18 92.46 95.26 80.57 84.26 91.88 87.90 86.32 83.24 81.84 74.67 75.91 72.00 45.49 45.85

* 1992 ** 1993. a) The elderly index is obtained by dividing the population aged 65 years or more by the population aged 0-14 years (per 100). Source: WHO, 1999c.

Similarly, life expectancy at 65 years in Italy has shown a progressively upward trend since 1970 for both sexes (Figure II.5a and Figure II.5b): during the last ten years (1983-1993), life expectancy at 65 years has increased by 2.3 years for women (+13.5%) and by 2 years for men (+14,5%). Improved longevity in Italy is mainly associated with decreased mortality from cardiovascular diseases (CVDs) at all ages and lower premature mortality for cancer (see Chapter IV). Increased longevity is a much better achievement if it is accompanied by good health and full autonomy. In order to take into account all the important factors, the concept of "Healthy” or “Disability-Free Life Expectancy" (DFLE) has been developed. However, healthy

life expectancy data are only available in Europe for a limited number of countries. An effective comparison of available data is made difficult by the different methodologies used for population survey (WHO, 1998b). In any case, available data (Table II.3) suggest that disability-free life expectancy in Italy for both men and women is closer to crude life expectancy than in other countries. These data also suggest that the gap in life expectancy between women and men narrows when considering DFLE, i.e. from 3.9 to 2 years at the age of 65. In a survey conducted in 1994, 1 874 000 people aged 65 years or more were found to be affected by disability, corresponding to a rate of

Italy as an ageing Society - 19

Table II.2: Elderly population and index in Italy by Region1 - 1996. REGION1

POPULATION OVER 65 YEARS (%)

POPULATION OVER 85 YEARS (%)

ELDERLY INDEX2

Piemonte Valle d'Aosta Lombardia Trentino Alto Adige Veneto Friuli Venezia Giulia Liguria Emilia Romagna Toscana Umbria Marche Lazio Abruzzo Molise Campania Puglia Basilicata Calabria Sicilia Sardegna

19.11 17.69 16.26 16.01 16.83 20.47 23.26 21.27 20.99 17.31 20.24 15.85 18.36 18.98 12.42 13.78 16.09 14.84 14.84 13.84

2.17 1.81 1.65 1.82 1.76 2.50 2.71 2.33 2.37 2.06 2.12 1.38 1.83 2.10 0.99 1.24 1.58 1.44 1.26 1.44

160.30 141.49 125.04 101.58 126.80 184.07 227.09 196.64 181.55 137.10 154.41 109.77 119.23 119.01 60.95 74.59 90.49 77.47 78.07 85.73

NORTH CENTRE SOUTH ITALY

18.26 18.46 14.20 16.82

1.98 1.84 1.27 1.69

147.76 139.81 75.69 113.24

1 In Italy, there are 19 Regions and two Autonomous Provinces (Trento and Bolzano) sometimes also reported as "Trentino Alto Adige". However, throughout this report the term "Region", particularly in Tables and Figures, also covers these two Self-Governed or Autonomous Provinces. 2 See Table II.1 for details. Source: based on ISTAT, 1997a.

20.8%. In Table II.4, estimates of the total number of people affected by disability according to age and type of disability are reported; each individual may have one or more disabilities (ISTAT, 1997b). However, it should be noted that as only old people living at home were considered in this study, the proportion of old people affected by disability may have been underestimated.

As expected, disability increases with age. In the very elderly (>80 years of age) more than 47% of people are reported to be affected by disability. Another useful health indicator is self-perception of health. Data from a cross-sectional survey carried out by ISTAT (Figure II.6a) show that the proportion of people reporting their health as "good" is reasonably high. Moreover, the percentage of elderly population with self-per-

20 - Italy as an ageing Society

Percentage

Figure II.3a: Population aged between 64 and 85 years or more in Italy Projection 2000-2050. Females.

Source: ISTAT, 1997a.

Calendar year

Percentage

Figure II.3b: Population aged between 64 and 85 years or more in Italy Projection 2000-2050. Males.

Calendar year Source: ISTAT, 1997a.

Italy as an ageing Society - 21

Table II.3: Comparison of life expectancy (LE) and disability-free life expectancy (DFLE) in years at age 65 for selected countries in Western Europe. MALES LE

FEMALES DFLE

LE

DFLE

Finland*, 1986

13.4

4.3

17.4

5.6

France*, 1991

15.7

10.1

20.1

12.1

Netherlands*, 1990

14.4

9.0

19.0

8.0

United Kingdom*, 1992

14.5

7.9

18.3

9.5

Italy, 1991**

14.9

12.2

18.8

14.2

* Source: Robine and Romieu, 1997. ** Source: ISTAT, 1995.

ception of health as "good" has improved from 1993 to 1996 (ISTAT, 1998a) (Figure II.6b). 2.2 Reduced natality Italy's birth rate is the lowest in Europe and indeed the lowest in the world today. The fertility rate began to decrease dramatically from the end of 1960s, until it reached a steady value of about 1.2 children per

woman during the most recent years, which is well below the replacement level of 2.1 (Figure II.7). There are marked differences among the Italian regions: in Southern Italy, the fertility rate is higher than in Northern and Central Italy (1.4 compared to 1 and 1.1, respectively, in 1995) (Figure II.8). Time trends tend to stabilize and those of the Southern regions become more similar to the values observed in the rest of the country.

TARGET 5 - HEALTH21 By the year 2020, people over 65 should have the opportunity of enjoying their full health potential and playing an active social role. In particular: 5.1 there should be an increase of at least 20% in life expectancy and in disability-free life expectancy at age 65 years. 5.2 there should be an increase of at least 50% in the proportion of people age 80 years enjoying a level of health in a home environment that permits them to maintain autonomy, self-esteem and their place in society.

22 - Italy as an ageing Society

Life expectancy (yrs)

Figure II.4a: Life expectancy at birth in EU countries. Females. Time trend.

Source: WHO, 1999c.

Calendar year

Life expectancy (yrs)

Figure II.4b: Life expectancy at birth in EU countries. Males. Time trend.

Source: WHO, 1999c.

Calendar year

Italy as an ageing Society - 23

Life expectancy (yrs)

Figure II.5a: Life expectancy at 65 years in EU countries. Females. Time trend.

Source: WHO, 1999c.

Calendar year

Life expectancy (yrs)

Figure II.5b: Life expectancy at 65 years in EU countries. Males. Time trend.

Source: WHO, 1999c.

Calendar year

24 - Italy as an ageing Society

Table II.4: People affected by disabilities in Italy in 1994. AGE CLASS

POPULATION

DISABLED PEOPLE

(YEARS)

(THOUSANDS)

NUMBER % OF THE (THOUSANDS) POPULATION

60-64 65-69 70-74 75-79 >80

3 3 2 1 1

066 166 590 288 946

182 287 369 302 916

5.94 9.07 14.25 23.45 47.07

NUMBER (THOUSANDS) OF DISABLE PER TYPE OF DISABILITY* BED

CHAIR

HOME

FUNCTIONS

MOVEMENTS

SIGHT, SPEAKING, LISTENING

11 20 26 34 96

14 17 18 22 87

22 59 73 50 227

121 151 232 218 732

73 134 169 134 429

23 42 68 51 183

* Includes more than once the same person if affected by different types of disabilities. Source: ISTAT, 1997b.

Figure II.6a: People perceiving their health as “good” in Italy, by sex and age group – 1996.

Source: ISTAT, 1998a.

Italy as an ageing Society - 25

Percentage

Figure II.6b: Population aged 65 years or more with self-perception of health as "good" in different areas of Italy - 1993 and 1996.

Source: ISTAT, 1998a.

Countries

Figure II.7: Fertility rate in EU countries - 1995.

Source: WHO, 1999c.

Average number of children per women of fertile age

26 - Italy as an ageing Society

Regions

Figure II.8: Fertility rate in Italy by regions - 1995.

Source: ISTAT, 1997d.

Average number of children per women of fertile age

CHAPTER III

A HEALTHY START IN LIFE

CONTENTS 1. INTRODUCTION ............................................................................... 28 2. INFANT MORTALITY ......................................................................... 28 3. CONGENITAL MALFORMATIONS...................................................... 30 4. BIRTHWEIGHT.................................................................................. 31 5. TEENAGE PREGNANCIES ................................................................. 31

28 - A healthy start in life

1. INTRODUCTION A healthy start in life includes events such as birth, physical development, learning to walk and talk, acquiring basic social and health values, discovering the environment and strengthening bonds to parents and people close to the family. A healthy birth establishes the basis for a healthy life. Pregnancy and delivery are natural

physiological processes – even though they may go wrong at times - and should be regarded as such by health professionals. The better a mother’s education, health and nutrition, the higher her socio-economic living standard and the quality of health-related services she receives, the greater the chance of a successful pregnancy. A healthy start in life is largely related to the lifestyles and parenthood skills of both parents.

TARGET 3 - HEALTH21 By the year 2020, all new-born babies, infant and pre-school children in the Region should have better health, thus ensuring a healthy start in life. In particular: 3.1 all member states should ensure improvements in access to appropriate reproductive health, ante-natal, peri-natal and child health services. 3.2 the infant mortality rate should not exceed 20 per 1 000 live births in any country; countries with rates currently below 20 per 1 000 should strive to reach 10 or below. 3.3 countries with rates currently below 10 per 1 000 should increase the proportion of new born babies free from congenital disease or disability. 3.4 mortality and disability for accidents and violence in under 5 year-olds should be reduced by at least 50%.1 3.5 the proportion of children born weighing less than 2 500 g should be reduced by at least 20% and the differences between countries should be significantly reduced.

2. INFANT MORTALITY Like most Western European countries, at national level Italy has met the regional WHO Health for All (HFA) target of an Infant Mortality Rate (IMR) below 10 per 1 000 live births. In 1994, the Italian infant mortality rate was 6.4 per 1 000 live births, a slightly higher value than the average for EU countries of 6.18 per 1 000 live births (Figure III.1).

1

See Chapter VI.

There are marked differences among the Italian regions (Table III.1); in some Southern regions the infant mortality rate in 1994 was still over 8 per 1 000 live births, i.e. almost three times as much as that of the Region with the lowest rate. From 1980 on, the IMR in Italy fell by more than 50% (this represents one of the largest improvements in Western Europe during this period) (Figure III.1); this decrease is still con-

A healthy start in life - 29

Deaths per 1 000 livebirths

Figure III.1: Infant mortality rate per 1 000 in EU countries. Time trend.

Calendar year

Source: WHO, 1999c.

Table III.1: Infant mortality in Italy by region – 1994. ITALIAN REGION

RATE (PER 1 000)

Piemonte Valle d’Aosta Lombardia Trentino Alto Adige Veneto Friuli Venezia Giulia Liguria Emilia Romagna Toscana Umbria Marche Lazio Abruzzo Molise Campania Puglia Basilicata Calabria Sicilia Sardegna

5.2 4.9 5.0 4.9 4.9 3.3 5.7 5.5 5.7 4.9 6.4 5.6 8.7 6.9 8.8 7.6 7.1 8.4 8.5 5.0

AVERAGE (ITALY)

6.4

Source: based on ISTAT 1997c.

30 - A healthy start in life

tinuing (Table III.2) although to a lesser degree.

3. CONGENITAL MALFORMATIONS Data on congenital malformations at birth are difficult to compare across countries because of different definition, diagnosis and registration practices. However, comparisons made using population-based registers from some areas of Italy participating in the European Registration of Congenital Anomalies (EUROCAT) network indicate that rates in Italy are comparable to other areas of Europe. For EU Member States, estimates are available from the EUROCAT project and from registers participating in the International Clearinghouse for Birth Defects Monitoring Systems (ICBDMS). In Italy, a network of registers exists, and some of them follow - at least partially - the EUROCAT methodology. Some also participate in the ICBDMS. The prevalence rates of all congenital anomalies, neural tube defects and Down syndrome (per 10 000 births) observed in the 16 registers that strictly follow EUROCAT methodology, including the Tuscany registry, are shown in Table III.3. The total prevalence rate of congenital malformation based on these 16 registers (1 418 126 births - live and still) is 227.1 per 10 000 births (including foetal deaths and induced abortions). Induced abortions represent an increasing part of the sample, i.e. 14.8% of the birth defects cases in 1994 (about 12% in the Tuscany registry).

Overall, compared to the distribution based on 1980-1992 data, a decrease in the proportion of neural tube defects, corresponding to a real decrease in frequency, can be observed (EUROCAT, 1997). The prevalence rates of neural tube defects are two to three times higher in the UK and Ireland, although they declined during the last 15 years (from a mean of 40 to 10-15 per 10 000). The prevalence rate of neural tube defects for the Tuscany registry in the period 1990-1994 is 6.6 per 10 000. Neural tube defects rates are 4.6 per 10 000 in Emilia Romagna and 6.1 per 10 000 in the North East respectively, compared to the Toscana rate and within the range of variability of the overall EUROCAT rates. However, an increase in cardiac defects, internal uro-genital anomalies and chromosomal anomalies was detected. This increase may be explained by a more efficient, more frequent and earlier performed prenatal diagnosis. Differences in the overall prevalence rate (19901994) of Down’s Syndrome (11.5 to 23.0 per 10 000 in Europe, 13.3 per 10 000 in Tuscany registry) are explained by different maternal age distributions and different rules for access to prenatal diagnosis and to abortion (EUROCAT, 1997). A further decrease in prevalence at birth of congenital malformations is indeed possible through a more extensive use of prenatal counselling and prenatal diagnosis. However, the effectiveness of this process is jeopardised by the limited knowledge of the causes of many birth defects.

Table III.2: Infant mortality in Italian areas (provisional data for 1996). ITALIAN GEOGRAPHICAL AREA

RATE (PER 1 000)

North-West North-East Centre South

4.7 4.8 5.6 7.4

Italy

6.0

Source: ISTAT, 1998a.

A healthy start in life - 31

Table III.3: Prevalence rate (per 10 000 births) of all congenital anomalies, neural tube defects and Down’s syndrome in the 16 registers following EUROCAT methodology - 1990-1994. REGISTRY

ALL CONGENITAL

NEURAL TUBE

ANOMALIES

DEFECTS

DOWN SYNDROME

ALL CASES

NUMBER

GLASGOW(UK) BELFAST (UK) GALWAY (IRL)* DUBLIN (IRL)* ODENSE (DK) NORTHERN NETHERLANDS ANTWERP (B) HAINAULT-NAMUR (B) PARIS (F) STRASBOURG (F) BOUCHES DU RHONE (F) SWITZERLAND TUSCANY (I) BASQUE COUNTRY (E) ASTURIAS (E) MALTA * Total

1 659 1 267 259 2 266 617 2 135 835 1 763 6 604 2 351 2 596 4 825 1 978 1 727 804 520 32 206

RATE

272.3 98.8 199.9 240.0 208.7 219.4 252.5 270.1 360.8 349.4 227.5 162.3 216.2 215.1 218.8 198.7 227.1

NUMBER

97 128 19 134 27 110 33 73 224 68 126 167 60 88 51 24 1 429

RATE

15.9 10.0 14.7 14.2 9.1 11.3 10.0 11.2 12.2 10.1 11.0 5.6 6.6 11.0 13.9 9.2 10.1

MATERNAL AGE

MATERNAL AGE

UNDER 30 YEARS

OVER 35 YEARS

NUMBER

RATE

NUMBER

RATE

NUMBER

RATE

105 162 33 193 46 115 38 96 513 119 231 353 122 155 52 54 2 387

17.2 12.6 25.5 20.4 15.6 11.8 11.5 14.7 28.0 17.7 20.2 11.9 13.3 19.3 14.2 20.6 16.8

44 53 4 44 10 30 16 36 96 46 58 114 29 28 15 8 631

11.2 6.5 6.8 8.7 5.2 5.6 7.3 7.9 11.2 10.5 8.7 6.6 6.5 7.3 6.8 5.2 7.8

36 71 22 108 21 39 9 37 304 52 104 127 61 77 24 34 1126

61.6 49.4 78.8 72.3 74.5 37.0 35.7 76.6 81.7 75.9 63.9 39.8 40.3 76.0 58.4 93.6 61.2

* Pregnancy termination is not legal in Ireland and Malta. Source: EUROCAT, 1997.

4. BIRTHWEIGHT Birthweight is related to social status and to other factors such as smoking. It is a marker for indices of deprivation and represents an accumulated risk over generations. Between 1990 an 1994, low birth weight rates (