Urbani izziv, thematic issue, 2015, no. 1 3 Roberto ZUFFADA Davide AZZOLINI Elisa MORGANTI Slavica ZEC The SPHERA project: Spatial planning and health systems for enhancing territorial governance in the Alpine Space Programme SPHERA is a transnational project cofounded by the Alpine Space Programme under the European Territorial Cooperation objective of the European Union’s cohesion policy. With a duration of sixteen months – from September 2013 to December 2014 – the initiative involved six partners with cross-sectorial expertise in both spatial planning and health, which are core dimensions of the operation: the Lombardy region (through the General Directorates for Health and Spatial Planning), the Slovenian central research institute for urban spatial planning and related disciplines (UIRS), the National Institute of Applied Sciences at the University of Lyon (INSA), the University Hospitals of Geneva (HUG), the Bruno Kessler Foundation (FBK) in Trento through its Institute for the Impact Evaluation of Public Poli- cies (IRVAPP), and the Research Centre for Health Innovation (IRCS) and the Kufstein Tyrol University of Applied Sciences (FHK) with the Department of Web Business and Technology with its area of study in eHealth. The spectrum of actors involved is completed by a number of project observers from the public and private sectors, including central and regional government authorities, academia and compe- tence centres. Capitalising on the results of Alpine Space Programme projects, SPHERA aims to enhance territorial governance focusing on inclusive growth in order to integrate healthcare in spatial planning at a transnational level by addressing issues such as demographic change and accessibility to services of general interest in order to improve social cohesion, wellbeing and quality of life. Learning from past achievements, SPHERA has the ambition to contribute to prepar- ing the ground for a new generation of projects in the Alpine Space Programme for the 2014–2020 period by identifying gaps and new areas for cooperation, and supporting synergies. Keywords: territorial governance, spatial planning, health, wellbeing 1 Introduction Territorial governance is one of the policy areas addressed by the 2007–2013 period of the Alpine Space Programme.[1] This priority line has explored concepts such as spatial planning, urban development, accessibility to services of general inter- est (SGIs), activities for social inclusiveness and demographic change, and models for inclusive and sustainable growth. Many Alpine Space Programme projects have addressed these issues, producing valuable results for these sectors of intervention, re- sulting in methodologies, tools, guidelines, recommendations and policy orientations. The topic “the future of urban areas” is central to sustainable development within the Alpine Space Programme: a new model of city has to be envisaged with a realistic approach that also takes into account the lifestyles of urban residents and their wellbeing. Health systems are also facing critical challenges linked to the need to redesign sus- tainable health models and governance of health systems in a developing territory in terms of services, resident population and budget constraints. Important issues affect the two dimen- sions of spatial planning and health systems, including the need to improve the quality of life and healthcare for elderly people and access to care for people living in remote and medically underserved areas; the need to face urban decline in terms of activities countering pollution, waste, traffic and poverty necessary to guarantee a healthy population living in a sustain- able city; and the necessity of strengthening inter-generational relationships, considering the ageing trend and demographic challenges, for ensuring a “re-humanised” urban area. The Alpine region is one of the most diverse areas in the heart of the European Union. It is an attractive working and Urbani izziv, thematic issue, 2015, no. 1 4 living space for seventy million people, covering an area of 390,000  km² and comprising some of the most important European metropolitan areas. It is also an important contact zone, including various European cultures and languages. The extent of territorial heterogeneity is one of the main features that distinguish the Alpine region from other parts of Eu- rope: mountains and surrounding areas, accessible and remote valleys, metropolitan regions and towns, lowlands and high plateaus all create different preconditions for economic and social development. Current demographic trends within the Alps show that in most Alpine areas there is an ageing process reflected in the share of people over sixty-four in comparison to the respective national average, with the exception of Austria, France and Slovenia (Villazzo, 2011). The Alpine Space Programme is an EU transnational co- operation programme for the Alps involving partners from the seven Alpine countries (Austria, France, Germany, Italy, Liechtenstein, Slovenia and Switzerland) working together to promote sustainable regional development. The programme is jointly financed by the European Union, through the Eu- ropean Regional Development Fund (ERDF), and the part- ner countries (members and non-members of the EU) tak- ing part in the activities. The overall programme budget for the 2007–2013 period amounts to almost EUR 130,000,000 devoted to increasing the competitiveness and attractiveness of the cooperation area by developing joint activities in ar- eas where transnational cooperation is required for sustain- able solutions. The Alpine Space Programme for  2007–2013 identified three thematic fields of cooperation, referred to as priorities: Competitiveness and Attractiveness, Accessibility and Connectivity, and Environment and Risk Prevention. In this context, the SPHERA project[3] falls under the Accessibil- ity and Connectivity priority, which among other things aims to secure fair access to public services, information, commu- nication and knowledge infrastructure within the programme area, enhancing connectivity to reinforce polycentric territorial patterns and lay the basis for a knowledge-driven information society promoting sustainable and innovative mobility models with specific regard to issues related to the environment, hu- man health and equality. 2 Project objectives The overall SPHERA project[4] objective is to enhance territo- rial governance in the Alpine area with respect to dimensions of spatial planning and health systems, addressing intervention areas such as accessibility to SGIs, demographic change, social inclusiveness and quality of life, with the aim of providing stra- tegic orientation across the thematic field of “inclusive growth” as one of the main priorities featuring the European Cohe- sion Policy for the next programming period (2014–2020).[5] From the long-term perspective, the project has the ambition to contribute to policy development in the targeted dimen- sions pursuing the following specific objectives: • Monitoring and emulating the experiences and results at- tained by the Alpine Space Programme projects in terms of transnational needs, policy development, institutional responsibilities and competence; • Evaluating and capitalising on the projects’ main quality achievements, through dissemination activities targeting the relevant policy level and actors, with the aim of verify- ing and measuring the impact on regional, national and European policies; • Identifying uncovered needs, challenges, opportunities and threats affecting the concerned areas; • Providing contributions for setting up a new generation of Alpine Space Programme projects beyond  2014 and supporting the creation of synergies between the Alpine Space Programme’s future programme period and initia- tives and programmes already in force and being defined at the European, national and regional levels making it possible to promote cross-fertilisation among policy- makers and decision-makers involved at various levels of governance. Based on spatial planning and health systems, the SPHERA transversal approach meets the Alpine Space Programme’s spe- cific objectives for enhancing balanced territorial development of the targeted territories and securing fair access to infrastruc- ture and SGIs and is fully coherent with the expectations to create added value for paving the way to the Alpine Space Programme for 2014–2020.[6] Furthermore, SPHERA is pur- suing the EU  2020 priority, which aims to build a cohesive society by reducing health inequalities, improving quality of life, promoting social inclusion and encouraging sustainable governance models in its policy development perspective. 3 The project’s methodological approach The SPHERA project’s methodological approach has been conceived along four main logical phases: 1)  analysis of achievements reached by the Alpine Space Programme pro- jects for 2007–2013 in the thematic field “inclusive growth” addressing health and spatial planning, 2)  capitalisation and valorisation of valuable project results, 3)  identification of common needs, trends and future challenges in the addressed areas and 4)  design of the prospective policy activities to be implemented for the new set of projects covering the period from 2014 to 2020. This approach relies on the conviction that both spatial planning and health topics are pillars of territorial R. ZUFFADA, D. AZZOLINI, E. MORGANTI, S. ZEC Urbani izziv, thematic issue, 2015, no. 1 5 governance and need to be addressed at a transnational level to maximise the lessons learned and the results achieved in this domain, transfer them to a broad audience of stakeholders and build up agreed-upon viable future pathways. By leveraging the need of developing joint activities in areas where transnational cooperation is required for sustainable solutions, the SPHERA project is eager to cross-analyse these dimensions in a unique scenario with the aim of clustering themes that can increase the attractiveness of the Alpine Space Programme cooperation area and that are complementary to diverse EU sectorial poli- cies and initiatives for inclusive growth. Because SPHERA is based on gathering, analysis and measurement of experiences from Alpine Space Programme projects generated in the past programming period, transnational cooperation, which is dis- tinctive of the Alpine Space Programme, is a prerequisite for the success of the initiative. These four logical phases have been grouped into two macro-activities called “methodology and analysis” and “mapping and shaping”. 3.1 Methodology and analysis This activity has pursued three main objectives: 1) to identify and analyse the transnational common needs and trends of the two dimensions addressed by the SPHERA project in the light of inclusive growth as a thematic field of the next cohe- sion policy programming period, 2) to map the achievements of the Alpine Space Programme projects from  2007 to  2013 with respect to these dimensions and 3)  to provide a list of socioeconomic indicators for viable means of evaluating policy impacts. These activities are devoted to preparing the ground for setting the scene of the Alpine Space Programme’s future projects (2014–2020) in health and spatial planning for en- hanced territorial governance. The outputs have been articu- lated through six deliverables: 1)  a report on transnational common needs and trends in the Alpine Space Programme, 2) a SPHERA atlas of the Alpine Space Programme including a panel of indicators suited for impact evaluation, 3) a meth- odology to identify relevant Alpine Space Programme project results, 4)  the SPHERA Synoptic Sheet (SSS) for collecting data on the projects analysed, 5) a report on the main project features, valuable results and capitalisation paths and 6) a mid- term workshop devoted to validating the analysis results and the panel of indicators to be used in the next macro-activity for setting up the map of major health and spatial planning issues that could be covered by the Alpine Space Programme 2014+ projects for enhancing the territorial governance strategy of the programming areas. 3.2 Mapping and shaping This activity had a twofold objective: 1)  to map, strengthen and further investigate the macro-areas and sub-areas identi- fied in the analysis phase previously carried out in order to understand and better qualify uncovered topics that could be at the core of the next set of projects in the Alpine Space Programme for  2014 to  2020 and 2)  to offer policymakers, decision-makers and stakeholders orientations and recommen- dations for driving the agenda setting of the future program- ming period. The first objective was implemented by setting up five thematic seminars that addressed and examined the main themes at the core of the health and spatial planning dimensions, and their relation from the perspective of inclusive growth. More specifically, seminars have explored these issues in consideration of the needs and trends identified through examination of the Alpine Space Programme’s  2007–2013 projects with the aim of mapping the current situation in the regions involved in SPHERA. Seminars have been targeting specific subjects and are customised to the local environment (government, academia, business and research). Furthermore, a gap analysis will be carried out in order to raise and point out topics relevant for spatial planning and health policies and plans and that could be central in projects initiated in the new programming period. The second activity is intended to move from the overall project results and finally propose novel direc- tions that the implementation of the Alpine Space Programme for 2014 to 2020 could take. 4 SPHERA analysis results 4.1 Transnational common needs and trends in the Alpine Space Programme According to the European Union, inclusive growth means “empowering people through high levels of employment, in- vesting in skills, fighting poverty and modernising labour mar- kets, training and social protection systems so as to help people anticipate and manage change, and build a cohesive society.”[6] It is about ensuring access and opportunities for all throughout their lifecycle and spreading economic progress to the entire EU, thus strengthening territorial cohesion. At the policy level, social inclusion is a pathway to achieving social justice and allowing all people a fair quality of life and full participation in both economic and social life (Forum of Non-Government Agencies, FONGA, 2011). Nevertheless, the World Health Organization (WHO) defines wellbeing not only as the absence of diseases or infirmity, but includes economic, social and psychological conditions (personal and collective). Therefore, wellbeing means satisfying quality of life through an adequate level of education and participation in social and economic life, beyond the absence of physical dis- eases. To secure a satisfying level of wellbeing, social inclusion and territorial cohesion are central issues. The SPHERA project: Spatial planning and health systems for enhancing territorial governance in the Alpine Space Programme Urbani izziv, thematic issue, 2015, no. 1 6 In giving all people a fair standard of quality of life, it is im- portant to look at them not as objects but as people with their own voice (FONGA, 2011). In this regard, the regional strategies introduce a new dynamic understanding of EU gov- ernance and the role of space or territories in an integrated European health policy. Therefore new interest is growing in integrated planning on health and spatial planning (Fauldi, 2010). At the strategy level, health and spatial planning are on the same plane; for example, the risk of ongoing territorial concentration of services for several mountain areas has a low quality in relation to new needs that cause a decreasing demand in existing services, thus triggering a vicious circle (Crawford, 2010). Accessibility to services for all, innovative solutions for health, designing spatial contexts for better quality of life, age- friendly cities and environments, urban peripheries that are more inclusive and green, and quality of housing: how can health and spatial planning improve the social inclusiveness of territories? How are health and spatial planning addressed in the reference policy and strategic framework at the European and regional levels? Finally, spatial planning is an important lever for promoting sustainable development and improving health and, more generally, the quality of life and social in- clusiveness. It is important that the Alps started an ageing process before the rest of Europe. Nevertheless, it is equally important that the causes of population ageing have not been exactly the same in the Alps and elsewhere in Europe (Crawford, 2010). A fun- damental demographic difference between the Alpine regions and Europe as a whole is represented by the far greater weight of out-migration, mainly younger people, as a factor conducive to structural ageing (Crawford, 2010). Heterogeneity within the Alps has been identified in areas with different specific features (Maurer et al., 2013; Table 1). The differences among Alpine areas are barriers that are not only due to topographical constraints, but also to political, linguistic and cultural identities. According to VicHealth,[7] there are four key reasons why factoring health into planning has a positive impact on population health (Barton, 2010). Good planning can: • Reduce inequalities between different socioeconomic groups for accessing houses, facilities and transport, and protecting vulnerable sectors of the population such as the elderly and children; • Increase the amount of incidental physical activity by improving access and providing walkable, mixed-use communities, thereby reducing the burden on disease, disability and mortality due to sedentary lifestyles; • Contribute to improved health of the population by re- ducing air and water pollution and greenhouse emissions, thus combating the threat of climate change; • Contribute to a changed social environment by improv- ing the liveability of the streets, making them safer and improving communication between people and commu- nity cohesion. In the light of these trends, the literature analysis focuses on the link between health and spatial planning policies, seeking to determine the extent to which they can contribute to inclusive growth. Particular emphasis has been placed on how spatial planning can be exploited to improve health and, more gener- ally, quality of life: spatial planning can directly affect health or it can have an impact on socioeconomic factors influencing the quality of life and thus health indirectly. Accordingly, within the framework of all-inclusive growth, this literature review goes in three main directions: • Analysis of the distribution of health outcomes across individuals, social groups or territory; • Analysis of the processes of generating the principal pa- thologies; that is, social factors that impact health and their distribution across social groups or territory; • Analysis of access to and quality of healthcare services and SGIs across social groups or territory. The literature about the Alpine region is vast and heteroge- neous, and many aspects of quality of life can be taken into consideration. Hence, it was necessary to narrow the focus of the SPHERA desktop research through a reasonable choice of several broad aspects of health and spatial planning: health status, access and quality to healthcare services, socioeconomic factors that impact health (such as poverty, deprivation, edu- cation,  etc.) and, finally, spatial planning for different scopes (such as accessibility, social inclusion and overall attractiveness of the Alpine Space Programme). Within each macro area, sev- eral sub-areas have been identified as clue dimensions that have been used as guidelines for the literature review (see Table 2). The outcomes of the analysis can be summarised as follows. The distribution of health outcomes largely follows recent EU outlines, in which inequalities in health (both physical and mental) and risky behaviours follow the patterns of so- cial inequalities. The literature shows that improved access to healthcare plays a major role in mitigating the adverse effects of social inequalities on health outcomes. Integrated care has the potential to reduce health access inequalities, and also to increase the efficacy and effectiveness of healthcare thanks to investment in ICT for healthcare. Systematic promotion of healthy behaviour also acts as a prevention mechanism for non-communicable diseases. Other channels through which comprehensive and well-structured territorial governance posi- tively influence both social and health outcomes have been assessed. An efficient housing policy that raises the quality of housing is an important factor for social inclusion, participa- R. ZUFFADA, D. AZZOLINI, E. MORGANTI, S. ZEC Urbani izziv, thematic issue, 2015, no. 1 7 Table 1: Specific features of different Alpine areas. Area Specific features Urban areas This includes thirty-seven regions (20% of all Alpine regions) characterised by medium-sized cities or su- burban areas and densely populated valley areas. There is a higher share of working-age people (fifteen to sixty-four years old) and the share of old people (over sixty-four) is clearly lower than average. Demographic growth is natural and also caused by in-migration. Dynamic city and rural areas This includes thirty-seven regions (20% of all Alpine regions) characterised by a large total of population, but usually with only one large centre surrounded by sparsely populated rural areas. The high population is caused by natural effects and strong in-migration. Ageing rural areas This includes twenty-two regions (12% of all Alpine regions) characterised by an average dense population, major metropolitan areas, or transition areas to a mountain region. There is very strong population ageing due to the low share of people under fifteen and people fifteen to sixty-four years old, combined with low natural growth and high in-migration of older people. The migration balance and age group shares give some evidence of a brain drain effect. Rural areas with out-mi- gration This includes sixty-nine regions (37% of all Alpine regions) characterised by sparsely populated small region (clearly below average), low natural growth and low in-migration determining population stagnation or decline and, in part, out-migration. Rural growing areas This includes fifteen regions (8% of all Alpine regions) characterised by a large overall population, but a less densely populated region with a high share of people under fifteen and significant natural population grow- th, as well in-migration triggering the total population development. Others This includes seven regions (4% of all Alpine regions) and metropolitan areas. Table 2: SPHERA macro-areas and sub-areas. Macro-areas Sub-areas Health status Physical health Mental health Risky behaviour Healthcare services Access to services and barriers to healthcare Quality and continuity of services Adequate health promotion and patient empowerment Socioeconomic factors that impact health Social class and inequality Income and poverty Material deprivation Education Social networks Migration and depopulation Demographic ageing Employment and work conditions Spatial planning and accessibility Accessibility to local facilities Accessibility to public transport Accessibility to the public or to SGIs Spatial planning and social inclusion Enhancing social networks and improving open spaces in facilities Quality of housing Social and institutional participation Increasing the attractiveness of Alpine Space Programme areas Economic competitiveness Tourism competitiveness The SPHERA project: Spatial planning and health systems for enhancing territorial governance in the Alpine Space Programme tion in social and economic life and reducing the sense of loneliness. An integrated mobility system tackles the uneven distribution of public transport and improves cross-border mobility, also facilitating access to general-interest services, which further reflects on the overall quality of life and the attractiveness of a particular area. Another special feature of both the EU and especially the Alpine area is the phenomenon of demographic ageing, which must not be ignored but turned Urbani izziv, thematic issue, 2015, no. 1 8 into a potential through fostering a “silver economy”. Strategies to avoid brain drain effects and the effective social inclusion of immigrants must also be taken into consideration because of considerable in-migration and out-migration. Finally, an over- all strategy to promote the potential of small Alpine towns by incentivising tourism and promoting polycentricism based on small towns should be a long-term goal that brings general benefits for particularly disadvantaged areas, which should not lose their comparative advantage but whose potential should be fostered and exploited. Complementary to this literature review, there is an analysis of the current policy and institutional reference frameworks of the territories covered by the project and addressing the most relevant priorities designed for facing health and spatial planning needs and challenges In a trans-national perspective, considering the Alpine region as a whole, heterogeneity is a relevant characteristic because of geographical and natural pre- conditions, demographic patterns, economic assets and social dynamics. Each activity to improve territorial cohesion and economic growth can take the specific context into account. Health and spatial planning have overlapping dimensions that can take different relevance due to context-based issues. Analy- sis of the policies leads to the conclusion that different regions show different patterns of policies for health and spatial plan- ning, starting with the type of government and the role of public sector. For example, Rhône-Alpes is characterised by the presence of a central state that controls the health sector, in contrast to other European countries. Tyrol’s health area is an example of extensive cooperation among a large number of operators, which represent central and federal institutions. Empowerment of patients is a priority in both Lombardy and Trentino, and in these regions as well as in Slovenia and Tyrol ICT solutions are receiving great attention. Regarding spatial planning, the Lombardy region places a priority on increasing quality of life for its citizens whereas Trentino focuses more on social inclusiveness and the valorisation of cultural, envi- ronmental and social identity. In these contexts, heterogeneity produces different needs and strategic orientations. In Slovenia the priorities are improving quality of life in rural areas and spatial economic development, including social integration and quality of life environment, with particular attention to social care and solidarity. Within the Lake Geneva region, the strategic objectives for spatial planning regard urbanisation for housing and economic development, mobility for public trans- port and the road network, and attention to rural areas for the landscape and agriculture. In its legislative framework, the Rhône-Alpes region has formalised the link between spatial planning and environmental and sanitation aspects, focusing particularly on preventing pollution and nuisances and on improving air quality. Preventing chronic diseases, promoting health, continuity of care, sustainability of healthcare, fair ac- cess to healthcare services, improving the quality of housing, coping with demographic change and ageing, stimulating so- cial inclusion, promoting social and territorial cohesion, im- proving public transport and infrastructure and ensuring access to SGIs are examples of common priorities in the policies of the member states of the Alpine Convention[7] in the framework of inclusive growth. Empirical research on decentralisation processes does not con- firm automatic positive effects on service delivery, economic development and social cohesion (Scott, 2009). Territorial identities and political contexts always affect decentralisation processes and the territories where they are implemented. In this regard, the concept of resilience plays a huge role, linked with local development and inclusive growth regarding so- cial inclusion, spatial planning and diffusion of wellbeing. Resilience is a concept that defines regions such as “systems within systems” (Lukesch et al., 2010), and therefore regions in a globalised world have to face their environment through political decisions, economic patterns and social behaviour (in- dividual and household). Hence, territorial resilience is the capacity to absorb external or internal stimuli and reorganise the structures, functions and relationships that are at the basis of development, maintaining sustainability intact. Managing and exploiting territorial resilience is a way to increase sustain- ability and territorial development. 4.2 Synthesis of the project results analysed by SPHERA In parallel with the literature analysis and regional policies dealing with health and spatial planning for inclusive growth in the Alpine areas, SPHERA has surveyed ten projects (see Ta- ble 3) selected among those already funded by the Alpine Space Programme (2007–2013) and INTERREG IIB (2000–2006) programmes and addressing the topics identified. The selected projects aim to improve the inclusive growth in the program- ming area seen from various perspectives through territorial governance. This analysis benefitted the entire set of methods and tools delivered for mapping the actual status of outputs in these policies as achieved by these projects. Furthermore, the analysis of the project results provided recommendations for constructing a methodological framework for future pro- ject evaluation design, which could serve for rigorous policy impact evaluation. The goal of this exercise was to identify the main achievements of these projects with the purpose of deriving valuable lessons for the next programming period and for further health and spatial planning policy development. Relevant project infor- mation was collected through a structured questionnaire (the SPHERA Synoptic Sheet) distributed to the projects’ lead partner and analysed and presented by topic, rather than by R. ZUFFADA, D. AZZOLINI, E. MORGANTI, S. ZEC Urbani izziv, thematic issue, 2015, no. 1 9 single project, because the goal was to obtain overall lessons for the future programming period and not to provide an as- sessment of individual projects and pilots. The analysis identified five topics clustering around the themes targeted by the projects: 1. Accessibility to SGIs; 2. The economic potential of small Alpine towns; 3. Public transport and mobility; 4. Healthcare accessibility; 5. Population ageing and new health challenges. The first three topics are closely related to a “spatial planning” dimension, and the other two are explicitly linked to health issues. Topics 3 and 4 could also be considered sub-topics of the first one because public transport and healthcare services are SGI. However, given the relevance of these two domains in the topics analysed, they are considered independently. The following sections briefly report the results of the analysis conducted in terms of problems framed by the projects, the main solutions and outputs produced, and a summary of the key lessons derived from the projects. 4.2.1 Accessibility to SGI Problem: within the projects analysed, the overall problem of SGI accessibility is framed as a consequence of concentration of SGIs in large urban areas and a reduction of SGI supply in more remote areas. This situation has negative consequences, such as: • Reduced territorial functionality and competitiveness of remote mountain areas; • Increased motorised mobility and environment pollution; • Exacerbation of age and social inequalities in SGI acces- sibility because these are the most vulnerable groups in the society affected by financial constraints and difficult mobility. Main solutions and outputs: the main solutions delivered by the projects include: • Organisation of marketing and awareness campaigns on Table 3: Transnational projects analysed by SPHERA. Project acronym Title Main themes ACCESS 1 Sept. 2008 – 31 Aug. 2011 Accessibility of SGIs. Organisational innovations in rural mountain areas Spatial and social equal accessibility to SGIs ALIAS 1 Aug. 2009 – 31 Oct. 2012 Alpine hospital networking for improved access to telemedicine services Healthcare provision in the Alpine area, fair access to healthcare services CapaCITIES 1 Oct. 2008 – 31 Mar. 2011 Competitiveness activities and policies for Alpine cities Increasing competitiveness of small Alpine urban centres DEMOCHANGE 1 Oct. 2009 – 30 Nov. 2012 Demographic change in the Alps: adaptation strategies to spatial planning and regional development Demographic change in mountain regions INNOCITÉ 1 July 2008 – 30 June 2011 How to improve competitiveness of small and medium-sized cities under the influence of large Alpine urban centres Raising competitiveness of medium-sized and small towns MORECO 1 July 2011 – 30 June 2014 Mobility and residential costs Spatial and transport development to cope with economic and demographic dynamics NATHCARE 1 Sept. 2012 – 30 June 2015 Networking Alpine health for continuity of care Demographic change, accessibility to healthcare, hospital-territory integration PUSEMOR* 1 Jan. 2005 – 30 June 2007 Public services in sparsely populated mountain areas Access to public services, rural-urban integration QUALIMA* Apr. 2003 – July 2006 Improvement by supporting public and private services in rural areas of the Alps Access to public and private services, social inclusion, preventing depopulation RURBANCE 1 July 2012 – 30 May 2015 Rural-urban inclusive governance strategies and tools for sustainable development of Alpine territories undergoing major transformation The relation among urban and rural areas and their development model Note: *Projects funded within the Interreg IIIB Programme. The SPHERA project: Spatial planning and health systems for enhancing territorial governance in the Alpine Space Programme Urbani izziv, thematic issue, 2015, no. 1 10 the topic of SGIs in remote areas; • Developing and implementing ICT-based and demand- oriented SGI delivery systems; • Organising training opportunities for SGI operators in remote areas; • Establishing services and social networks to reach more vulnerable groups (including the elderly). Lessons for policy development: • ICTs and organisational changes are powerful tools for bridging physical gaps; • It should be kept in mind that individuals’ purchasing behaviours change slowly; • ICT-based solutions should be tailored to the needs of the elderly and other vulnerable groups. 4.2.2 Economic potential of small Alpine towns Problems: the projects analysed identify two main sources that hamper economic performance in Alpine areas: • Critical economic and social factors (accessibility, de- creasing population and workforce size, etc.); • Suburbanisation from larger peri-Alpine large cities. Main solutions and outputs: projects on this topic mainly focused on the importance of defining innovative territorial growth strategy in a participatory way: • New “governance” solutions through the integration of policies, across administrative borders and policy do- mains; • Alliances with neighbouring “metropolitan growth areas” (e.g.,  in agriculture, commerce and tourism); • Innovative urban policies. Lessons for policy development: • Future scenarios and long-term development strategies should be defined in a participatory manner; • A new generation of integrated planning (local and re- gional levels and metropolitan areas) is needed; • Economic valorisation of local resources should be pursued. 4.2.3 Public transport and mobility Problems: finally, the projects addressed the issues of transport and mobility in rural areas, emphasising that: • Urban sprawl further increases public transport costs; • Private motorised transport causes environmental pollu- tion, traffic congestion and health costs. Main solutions and outputs: • Active support of sustainable, resource-friendly settle- ment development to reduce mobility needs and costs; • Special transport solutions and services were introduced for elderly residents, tourists and commuters; • Creation of a unique mobility centre. Lessons for policy development: • Support the efficiency of public transport by concentrat- ing (future) settlement; • Promote flexible and demand-oriented transport models; • Fix minimum standards for public transport; • Integrate proposed activities into existing policies. 4.2.4 Healthcare accessibility Problems: healthcare accessibility is a sub-domain of the pre- vious topic, with some additional and noteworthy problems, such as: • The low availability and quality of healthcare services in mountain areas; • The difficulty in serving new health demands (e.g.,  age- related ones) in remote areas, which gives rise to social inequality in health. Table 4: Project distribution across the five topics. Project Accessibility to SGI Economic potential of small Alpine towns Public transport and mobility Healthcare accessibility Population ageing and new health challenges ACCESS X X ALIAS X CAPACITIES X DEMOCHANGE X X INNOCITÉ X MORECO X NATHCARE X PUSEMOR X QUALIMA X X X RURBANCE X R. ZUFFADA, D. AZZOLINI, E. MORGANTI, S. ZEC Urbani izziv, thematic issue, 2015, no. 1 11 Main solutions and outputs: solutions proposed and imple- mented by the ten projects mainly targeted innovation in healthcare supply and management: • Creation of a virtual hospital (a hospital network sharing data and clinical expertise); • Developing and implementing eHealth services (“tele- consultation” and “second opinion”); • Creating new organisational models and data sharing for networks of volunteer associations; Lessons for policy development: • Implement eHealth solutions to reduce the distance be- tween patients and providers and to allow the healthcare system to recognise needs and respond effectively; • Develop eHealth solutions together with healthcare pro- fessionals to improve utilisation and quality of services; • Provide training of health professionals on the use of new technologies; • Build trust and confidence in telemedicine applications among users. 4.2.5 Population ageing and new health challenges Problems: although it is well known that population ageing places burdens on health and social systems, there is less aware- ness of the fact that demographic change is also a major issue for regional development and spatial planning, and that spatial planning policies might serve as leverage for increasing the wellbeing of the elderly in mountain areas. Main solutions and outputs: • The projects aimed at raising awareness of the topic by mobilising and activating different types of stakeholders at the local level; • Local healthcare communities were also created to sup- port a network of stakeholders that can support the el- derly’s access to healthcare; • Specific initiatives were undertaken to improve tourism for the elderly in the Alps (promotional initiatives, tours, hiking paths, etc.). Lessons for policy development: Adaptation to demographic change should be seen as an ob- ligatory target and a priority field of activity in regional plan- ning and regional development: • Improve utilisation of current demographic monitoring tools and processes (e.g., Eurostat and national statistics offices); • Improve housing, mobility and independent living for elderly people; • Improve the social integration of elderly people; • Adapt tourism infrastructure and services to elderly tourists. The final step of the analysis considered a possible way to strengthen the evaluability of Alpine Space Programme pro- jects in the next programming period. Although some of the projects considered above were subject to monitoring, a sound and systematic evaluation approach was missing. Such a defi- ciency is partly attributable to the nature of the projects, which are broad in scope and types of activities, and are therefore difficult to evaluate. The recommendations raised by the SPHERA analysis is to strengthen the practice of evaluation in the next Alpine Space Programme period along three lines: • Improving the evaluability of projects and pilot activities (Evaluability Assessment); • Embedding evaluation in projects and pilot activities from the beginning (Prospective Evaluation); • Exploiting available databases that allow systematic monitoring of relevant outcome indicators (Outcome Indicators). 5 Conclusion Alpine healthcare systems faced many challenges, thus de- manding a change towards sustainable health models and governance. Spatial planning in the Alpine regions should be considered from a perspective allowing the integration and harmonisation of different policies, including health, in order to enhance territorial governance for the wellbeing of all. Demographic and social changes produce variations in life- styles, only partially explained by current policy models. The inadequacy of these models calls for the identification of new paradigms enabling interpretation of phenomena with a col- lective dimension traceable in urban and peripheral areas, such as social disparity and marginality, a shortage of environmental resources, health inequalities and relevance of the landscape in public health. These aspects combine two domains  – spatial planning and health – that only apparently operate in different contexts. Their integration in a common policy approach can provide novel momentum to face challenges that have been often tackled separately. Territorial governance needs a new strategy design that com- bines different dimensions and includes the opportunity to integrate urban planning with healthcare policies. In this light, programming should be inclusive and planned in a par- ticipatory manner, involving all relevant stakeholders, should be addressed towards sustainability considered from various perspectives (social, cultural, environmental and clinical) and should target topics such as health, promoting a healthy life- style, preventing disease, urban renovation for fighting social exclusion, healthcare and the landscape to promote a better The SPHERA project: Spatial planning and health systems for enhancing territorial governance in the Alpine Space Programme Urbani izziv, thematic issue, 2015, no. 1 12 quality of life and wellbeing. Furthermore, from the analysis carried out through SPHERA, some specific issues could re- quire coordination between spatial, social and health policies and be a foundation for new directions for searching for trans- national initiatives: ageing in peripheral areas and providing relevant services enabling the social integration and inclusion of elderly people. There is a need to improve the use of new technologies by healthcare professionals, specifically in remote areas. Other issues include health service accessibility in pe- ripheral areas at all levels, finding the proper ratio between the concentration and dispersion of services taking into account cost-effectiveness, efficiency and flexibility; securing adequate housing for the elderly in peripheral areas (maintenance, fi- nancing, security and green areas) ensuring independent living, physical accessibility and adequate design of public spaces, and mobility (new needs given ageing). Finally, health represents an overall topic that cuts across many areas. Thus it is recommended that impact assessments be used to improve compliance with policies and also for an ex-ante assessment of potential policy impacts for a given spatial unit (health impact assessment, social impact assessment and ter- ritorial impact assessment). Complementary to this recom- mendation, a more general, sound and systematic evaluation approach towards projects and specific pilot activities should be ensured to monitor and assess the effectiveness of the results and therefore their capitalisation and valorisation in practice and policies. Roberto Zuffada Lombardia Informatica s.p.a, Milan, Italy E-mail: roberto.zuffada@cnt.lispa.it Davide Azzolini Research Institute for the Evaluation of Public Policies, Fondazione Bruno Kessler (IRVAPP), Trento, Italy E-mail: azzolini@fbk.eu Elisa Morganti Research Centre for Health Innovation, Fondazione Bruno Kessler (IRCS), Trento, Italy E-mail: morganti@fbk.eu Slavica Zec Research Institute for the Evaluation of Public Policies, Fondazione Bruno Kessler (IRVAPP), Trento, Italy E-mail: zec@fbk.eu Acknowledgements Financial support from the Alpine Space Programme ERDF co-fund- ing, grant no. SPHERA 10-5-2-IT, is gratefully acknowledged. This pub- lication does not necessarily reflect the Alpine Space Programme bodies’ views and in no way anticipates their future policy in this area. 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