This case study shows some interesting examples of attempts to bring about an integrated approach to regional planning that embeds health-related considerations. Meaningfully enough, some of these attempts have taken place at the local/county level, where the interest of trans-sectoral thinking is best evidenced. Officials in the MA recognise, however, that health has traditionally been a second-order concern in Structural Funds programming in the region.  The main reason for this seems to be the relatively low prominence of potential indirect health gains in the Community Strategic Guidelines on Cohesion.

Impacts on health of projected investments are in the region’s OP, at least at three different levels. First, it refers to human health in its strategic analysis as well as its SEA (drinking water quality; improvement of access to health information through broadband development). Second, it addresses safety-related issues in the context of transport infrastructure. Third, it acknowledges the role of ERDF interventions to mainstream the promotion of social inclusion in Member State’s health policies, as well as to “yield innovations in areas such as healthcare and environmental technologies which make tangible improvements to our way of life.”

According to the Director of the BMW Regional Assembly, a “good” consultative process has been built into Structural Fund planning and there is also a good record of inter-institutional dialogue in Ireland through the national partnership process. However, unlike in the 2000-2006 programming period, when the Irish Health Department was involved in Structural Funds planning and represented in the Regional OP Monitoring Committee, there have been no specific contributions from health authorities during the planning stage of the 2007-2013 OP.

Although health authorities were represented on the Operational Committee, they did not make specific comments nor were they consulted as part of the public consultation process. Among the some possible explanatory factors for this situation, this official mentioned the absence of direct funding from the Structural Funds for health interventions, limited institutional capacity and limited resources.

The Managing Authority’s Director also declared that, for potential health gains of SF interventions to be systematically and efficiently taken into account in the planning process, health needs to figure “higher up on the agenda”. For this purpose, the assessment of these gains should be explicitly mentioned in the Community Strategic Guidelines and/or be made compulsory under applicable regulations.

To this regard, the Managing Authority’s Assistant Director suggested that health gains could become a horizontal issue in the new Cohesion Policy. All the more since there have already been successful collaborative actions between the OP Managing Authority and relevant Departments (Social Inclusion Unit, Environment Policy Unit, Gender Equality Unit and the Irish Equality Authority) to develop guidance documents on how to address the horizontal priorities set out in Structural Funds regulations (gender, environmental sustainability, broad equality and social inclusion).

 

 

Background information

Negotiations in the context of the Agenda 2000 Agreement on Agriculture resulted in the designation of two NUTS II regions for Structural Funds purposes: the Border Midland and Western (BMW) Region and the Southern and Eastern (S&E) Region.[1] Created in 1999, these are among the newest NUTS II regions in the EU15.

The BMW Region accounts for 47% of Ireland’s land surface and about 27% of the country’s population with 1.19 million inhabitants.[2] It is divided into three Regional Authority areas that are NUTS III regions (see map below). It encompasses thirteen counties including the six border counties of Donegal, Sligo, Leitrim, Cavan, Monaghan and Louth; the three western counties of Galway, Mayo and Roscommon and the four midland counties of Laois, Offaly, Longford and Westmeath.[3]

Figure 1: Administrative divisions in the BMW region

 

Description: Region-map

Source: Border, Midland and Western Regional Operational Programme. Supporting and Enabling Dynamic Regions. December 2010

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

Population (inh., 2010)

1.189m

Surface area (km2)

32,481

GDP per capita in EUR (PPS, 2008)

23,300

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

93%

Cohesion Policy status

Competitiveness and Employment (phasing-in)

Life expectancy at birth, male (2008)

77.1

Life expectancy at birth, female (2008)

82.3

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

Although the BMW Region is predominantly rural, with a low population density, a network of small and medium-sized towns has developed in recent decades. The region enjoys a high-quality living environment: there are notably low levels of air pollution and transport congestion. This may partly explain the fact that, in 2008, life expectancy at birth in BMW was higher than the EU27 average: 77.1 years for men and 82.3 years for women compared to, respectively, 75.8 and 82 years. Demographic growth is however an increasing source of pressure on living conditions. 

The economy of the BMW Region is moving away from a strong reliance on agriculture toward a greater role for high value added sectors. However, in comparison with the rest of the country, the region still suffers from low levels of innovative activity, brain drain phenomena and a deficient (if improving) knowledge transfer infrastructure. Consequently, the region has per capita income levels that are well below those of both Ireland’s Southern and Eastern region and national average, although it nears the EU27 average p/c GDP as shown in the figure below.

Figure 2: Per capita GDP for Irish NUTS II regions and Republic of Ireland, in PPS (UE27 average = 100)

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

In terms of overall development, however, BMW scores above the EU average on the EU version of the UN’s Human Development Index (HDI).  This index includes healthy life expectancy, household income, and educational attainment levels. In 2007, the region scored 70.3 out of 100 compared to an average value of 62 for EU regions.

 

 

Policy and institutional overview

Cohesion Policy

In Ireland, only ERDF assistance is programmed and managed at regional level. ESF assistance is in turn managed at national level by the Department of Enterprise, Trade and Employment (Human Capital Investment Operational Programme). In the current programming period, BMW is a “Competitiveness and Employment” region with phasing-in status. According to DG REGIO programme information sheets, this involves “a frontloading of community assistance in the early years of the programming period”.[4]

ERDF interventions in the BMW Region are conceived as “niche investments” to complement those programmed in the EUR 184bn National Development Plan (NDP) 2007-2013, a high level national strategic document which sets out indicative investment allocations. As a result, ERDF interventions focus on Research and Technological Development, competitiveness and connectivity and urban development. As shown in the table on the next page, over EUR 228m in EU funding have been allocated in the BMW ERDF OP, which amounts to approximately 30% of Structural Funds allocations to Ireland under the Competitiveness and Employment Objective.

The table on the next page summarises the key priorities and intervention areas of the OP, as well as their correlation with the proposed briefing sheet topics. Whenever applicable, the tables also show health considerations within each priority.

Table 2: Financial plan of the Border, Midland and Western Regional Operational Programme

BMW Regional OP 2007-2013 (ERDF only)

MA:  BMW Regional Assembly

Total EU allocation: € 228.76m

Priority Axis

Funds[5] (€m)

Percent of total OP

Content of priority

Briefing Sheet topic(s)

Health considerations in the priority

Innovation, ICT and the Knowledge Economy

102.50

44.81%

 

Applied Research, Innovation

Incubation Facilities and Collaboration initiatives

Research

Microenterprise Innovation and Entrepreneurship

Broadband Provision and Demand Stimulation

Science Foundation Ireland Awards

RTD

ICT

Institutional capacity

Potential investment to boost research capacity in bio-pharma and medical devices sectors

Environment and

Risk Prevention

30

13.11%

 

Water

Water Supply and Waste Water Treatment

Water Conservation

Natural and Cultural Heritage

Waste Management 

Energy Efficiency and Renewable Energy

Biodiversity

Infrastructure: waste

Infrastructure: water

Energy

Investments to protect vulnerable water sources from point and diffuse sources of pollution (particularly in rural areas)

Urban Development and Secondary Transport Networks

94.25

41.20%

 

Urban Regeneration

Key Linking Routes

Public Transport

Urban and rural regeneration

Transport

 

 

Safety improvements including of layout of junctions and access points

Promotion of public transport as safe mode of travel

Technical Assistance

2.01

0.88%

 

Cross-cutting

N/A

 

Total BMW OP

228.76

100%

 

 

 

Source: Border, Midland and Western Regional Operational Programme. Supporting and Enabling Dynamic Regions. December 2010.

Managing institutions

The Managing Authority for the ERDF is the BMW Regional Assembly. It is in charge of preparing and delivering the BMW Regional Operational Programme, the implementation of which is overseen by the Operational Programme Monitoring Committee.

The Certifying Authority is the Department of Finance, which certifies declarations of expenditure and applications for payment before they are sent to the European Commission.

The Audit Authority is the ERDF Financial Control Unit. It is functionally independent of the Managing Authority and Certifying Authority and is responsible for the effective functioning of the management and control system.

The Intermediary Bodies are responsible for certification of all expenditure incurred by Beneficiaries (i.e. ensuring, in respect of co-financed Interventions/projects, that only eligible expenditure actually incurred is submitted to the Managing Authority).

Health sector

Irelandhas centralised management of health policies. The responsibility for policy design, including public health, lies with the Department of Health, whose mission is “to improve the health and well-being of people in Ireland in a manner that promotes better health for everyone, fair access, responsive and appropriate care delivery, and high performance”.[6]

The Health Service Executive (HSE) is has in turn primary responsibility for delivering health and social services across the country. The main health-related policies and objectives are set out in the HSE Annual Services Plan 2011. These include:

  • Maintaining the levels of service provided in 2010:
  • Delivering the cost reduction and restructuring programmes to enable the maintenance of these service levels on a total reduced budget basis of EUR 962m (EUR 683m net)
  • Seeking to ensure the delivery of high quality and safe services
  • Accelerating the HSE reform programme to reconfigure core services and in line with HSE strategy, deliver an appropriate balance between hospital and community services as well as best care models in childcare, disability, mental health and older person’s services
  • Implementing the national clinical change programmes and new service developments

As far as public health is concerned, Irish health policies have a very strong preventative component, particularly vis-à-vis cancer, infectious diseases and cardio-vascular disease.

 

 

Health in the Structural Fund programmes

Unlike in most of the convergence regions, health infrastructure projects are not eligible for Structural Funds assistance in competitiveness and employment regions in the current programming period. As a result, there are no direct investments in health care in the BMW OP. These investments are instead planned at national level, in the National Development Plan. However, some of the ERDF allocations to the region are being used for health-relevant purposes despite lacking “health” earmarking; e.g. technological research contributing to the development of medical devices, urban renewal, improvements to water quality and supply, etc.

In addition, the BMW OP does refer to human health in its strategic analysis as well as in its SEA. The OP also addresses safety-related issues in the context of investment priorities.

Under its policy context section, with regard to the Lisbon Strategy, the region’s OP acknowledges the role of ERDF interventions to “mainstream the promotion of social inclusion in Member State’s employment, education and training, health and housing policies. It likewise stresses that “investment in research and innovation is essential for both economic competitiveness and innovation in areas such as healthcare and environmental technologies which make tangible improvements to our way of life”.

When referring to the results of the Ex-ante Evaluation and Strategic Environmental Assessment (SEA), the OP claims to have taken on board the recommendations arising from the SEA process with regard to the ongoing monitoring of its impacts on population, human health and biodiversity, flora and fauna, and water. The OP also refers to “human health” within the context of the SEA monitoring measures, in connexion with drinking water quality.

In its SWOT Analysis, the OP refers to “gaps in the provision of health, social, cultural and leisure facilities” as one of the region’s weaknesses.

Priority 2 Environment and Risk Prevention foresees investments to protect vulnerable water sources from point and diffuse sources of pollution, particularly in rural areas, as well as to decrease reliance on “harmful energy sources”. However, the OP does not link these investments to any specifically health-related target.

Priority 3 Urban development and secondary transport networks foresees the allocation of funds for safetyimprovements including the layout of junctions and access points. It also supports public transport development in major urban centres in the region on the grounds that this mode of travel is “safe”.

Beyond the realm of Structural Funds, public health is notably taken into account in existing regional guidelines for the development of the National Spatial Strategy (NSS), a 20-year strategy for spatial development in Ireland. More precisely, the guidelines for the Border region insist that “due consideration must be given to the factors that impact on the health of the population”.

 

 

Integrating health in the programmes

This section covers the process and experience with integrating public health issues into the planning of the Structural Funds OP in the BMW region, as well as the implementation and monitoring, where applicable. It also focuses on health-relevant cross-border institutional cooperation in border areas. 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.

Health as a driver for inter-institutional cooperation

A specific collaborative initiative in the health and social care sector in the Irish border region, which is substantially supported by EU Funds (Peace Programme & Interreg IVA Programme), was reported by a corporate management official at the HSE. Itis particularly worth mentioning in this case study for the following reasons. On the one hand, this initiative, Co-Operation & Working Together (CAWT)[7], has developed models of service provision in the border corridor area based on collaboration and joint working between Health Agencies in both jurisdictions. On the other hand, it is of special significance in the Irish context since “it has provided several different strings for inter-institutional cooperation in other areas”, many of which have implications for public health.

Health in the BMW OP

Both the Director and the Assistant Director of the BMW Regional Assembly confirmed that health was not explicitly considered during the preparation of the regional OP. According to the Assistant Director, “health has been up to now a secondary, indirect issue”, and  the programme is not designed for conscious integration of health-related considerations (with the exception of the SEA of the OP: water quality, improvement of access to health information through broadband development).

This official suggests two main explanatory factors for this. First, direct investments in health infrastructure are not eligible for non-convergence regions under the Community Strategic Guidelines on Cohesion. Second, and more generally, potential indirect health gains are not particularly prominent in these Guidelines.

According to the a corporate management official at the HSE, some Structural Funds interventions in the region have however been particularly successful in addressing health determinants and improving health outcomes. He points out that health gains stemming from these interventions may not have been explicitly or systematically acknowledged in OPs nevertheless. These successful interventions typically relate to the improvement of road infrastructure, which is helping to decrease road fatality rates while enhancing access to health care services, thus improving clinical outcomes. Broadband development in peripheral areas, which enables remote diagnosis and, more generally, improved access to health services, is also a major breakthrough according to this official.

Health gains from non-health investments: a local perspective

The Director of Services in the Westmeath County Council stressed the significance for public health of two non-health Structural Funds projects in the area, as both acknowledged explicitly in their grant request documentation the potential health gains they would entail.

The first one consists of a EUR 20m project to construct 20km of cycleways linking residential areas to schools, business districts and central urban areas in a municipality of 18,000 inhabitants. According to the Director of Services in the local authority, related documentation highlighted the project’s potential public health benefits in terms of reduced obesity and healthier lifestyles, particularly for the youth.

The second project involves support to the construction of an art gallery and art studios in Athlone. According to the Director of Services in the local authority, grant request documentation stated that, by contributing to social inclusion (the programme of activities was specifically designed for this purpose), this project would bring significant public health gains.

This official noted that this explicit, ex-ante acknowledgement of the potential health gains of non-health projects was “very unusual” according to his own knowledge and experience.       

The consultation process toward the 2007-2013 BMW OP

National development strategies for Ireland, which are embodied in the National Development Plan (NDP), are designed on the basis of stakeholder participation, with health authorities playing an important role in the process according to the HSE official consulted.

Health authorities are likewise well represented throughout the planning process for Structural Funds. The Department of Health contributes to EU funding and policy programmes both directly through its own representative based in Brussels and by working on an inter-departmental basis at national level. The HSE has representatives in the Operational Groups of the Regional Assemblies which provide an opportunity to comment on the health gain aspect of EU Structural Funds Programmes when they are tabled for discussion. During this process, the HSE “has consistently articulated the message that socioeconomic conditions (housing, employment, food and water quality, etc.) have a major bearing on public health”.

According to the HSE official consulted, the policy position of Irish health authorities with regard to Structural Funds planning, which has remained relatively stable over the years, has focused on the “macro” dimension: “if it is good for the well-being and prosperity of the community, then it is good for public health”.  He added that there is a general recognition in the health services in Ireland of the variety of socioeconomic health determinants which exist and of the necessity for “well co-ordinated inter-agency approaches”. Therefore, the health sector “directly inputs to the Regional Assemblies’ and Regional Authorities’ consultations”, and is “widely represented on Area and Local Partnership Agencies whenever specific EU-funded programmes are place to deal with Social Inclusion through capacity building and local initiatives”. These are all based on a "target group" approach to assist vulnerable groups and individuals.

The Director of the BMW Regional Assembly observed, in turn, that a “good” consultative process has been built into Structural Funds planning, and that there is a good record of inter-institutional dialogue thanks to the National Partnership process. He noted, however, that whereas health authorities were represented on the OP’s Operational Committee, they did not make specific comments or were consulted as part of the public consultation process. The following are some possible explanatory factors according to this official:

§  no direct funding from Structural Funds for health interventions (not eligible)

§  inadequate timing

§  low levels of awareness by health/regional authorities (as Structural Funds are not associated with health investment)

§  limited institutional capacity and limited resources

According to the Assistant Director of the BMW Regional Assembly, this situation is to be compared with the 2000-2006 programming period, when investment projects for the development of childcare facilities and services were eligible in Ireland under ERDF and ESF regulations. The Irish Health Department was consequently involved in Structural Funds planning and represented in the Regional OP Monitoring Committee. As previously stated, these projects (and, more generally, direct investments in health) are no longer eligible in the current programming period, and this Ministry is therefore no longer represented in the Monitoring Committee. Unlike some of its counterparts, the Health Department did not provide any specific inputs during the preliminary consultation or formal consultation processes either, according to this official. 

The Assistant Director pointed out that there have, however, been noteworthy collaborative actions between the Managing Authority and relevant Departments (Social Inclusion Unit, Environment Policy Unit, Gender Equality Unit and the Irish Equality Authority) in the context of developing guidance documents on how to address the horizontal priorities set out in applicable Structural funds regulations and national guidelines  (gender, environmental sustainability, broad equality and social inclusion). He therefore suggested that “a similar process could be followed for health gains as a ‘horizontal’ issue”.

The Director of the Assembly believed however, that there is limited scope for the development of partnerships between the managing authority and health authorities ahead of the next Cohesion Policy programming period. This is, he said, due to dwindling EU financial assistance and shifting priorities, as the financial and economic crisis are presently major concerns. He indicated that these partnerships would probably have gathered momentum more easily a decade ago.

Further needs

It was the view of the Assembly’s Director that, for potential health gains of SF interventions to be systematically and efficiently taken into account in the planning process, health needs to figure “higher up in the agenda”. For this purpose, he recommended that the assessment of these potential health gains be explicitly mentioned in the Community Strategic Guidelines and/or be made compulsory under applicable regulations. 

He also observed that ex-ante assessments are of particular relevance for good policy design, but that resource limitations at the managing authorities mean that the integration of health into OPs at this stage can only be successful if compliance-driven (“the stick would, in this case, work better than the carrot”). This view was shared by its Assistant Director, according to whom, unless issued through official EU channels, guidance on the assessment of potential health gains from Structural Funds investments (or, for that matter, any EU co-financed investments) risks being sidelined due to resource constraints and other priorities advanced by the EU Commission.  

 

References

Print sources

Border, Midland and Western Regional Assembly: Border, Midland and Western Regional Operational Programme “Supporting and Enabling Dynamic Regions”, December 2010. http://www.bmwassembly.ie/NEWOP_2007-2013/NewOP_Docs/BMW_OP_September_2009.pdf

Irish Government, Department of Finance: The National Strategic Reference Framework for Ireland “Supporting and Enabling Dynamic Regions”, EU Regional Policy 2007-2013. http://www.bmwassembly.ie/newop_2007-2013/NewOP_Docs/FINAL%20NSRF%20as%20approved%20by%20the%20Commission%2027-7-07.pdf

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

Joint submission by the North Eastern Health Board and the North Western Health Board: “Implementing the National Spatial Strategy: Regional Planning Guidelines for the Border Region”, 2004. 

Interviews

Interviews with regional health authorities

Tom Daly, Corporate Management Official, Health Service Executive, 9 May 2011.

Interviews with the Managing Authority

Gerry Finn, Director of the Border, Midland and Western Regional Assembly, 27 April 2011.

Kieran Moylan, Assistant Director of the Border, Midland and Western Regional Assembly, 27 April 2011.

Interviews with local authorities

Barry Kehoe, Director of Services: Transportation, Planning, Community and Enterprise, Athlone and Kilbeggan Areas, Westmeath County Council, 10 May 2010.


[1]Irish Regions Office (IRO): http://www.iro.ie/bmw_assembly.html

[2]Eurostat, data for 2008.

[3]The Irish Regions Office > Regions of Ireland > The BMW Region: http://www.iro.ie/bmw_assembly.html(accessed 12 April 2011). This section draws substantially on this online resource.

[5]Based on latest financial plan submitted to EU Commission following Mid-Term Evaluation of the BMW Regional OP.