The Hon. Roberto
The ageing of the population has been - like in all industrialized and in many developing countries - a characteristic of the demographic dynamic of Italy over the last few decades, and most probably will remain so in the next ones. In Italy the fertility rate has declined - currently the total fertility rate stands at 1.25 births per woman of child-bearing age - while the expectation of life has increased in 2001 to 76.7 years for men and 82.9 for women, and continues to grow: According to the latest UN estimates it could reach 81 and 86 years of age for the two sexes, respectively, by 2050. For the combination of these two factors Italy has the oldest population of the planet, in as much as it has at the same time the highest percentage in the world of population aged 65 and over (18.1) and the lowest percentage of population aged 15 and below (14.1).
The most serious problems come from the speed and the intensity of the ageing of the Italian population, which make Italy a sort of demographic, economic and social "laboratory". Avoiding that the population ageing becomes also an economic and social ageing is our imperative: adequate, timely and dynamic measures should be implemented at international, national and local level. Since Italy is in the forefront in this field, we cannot avail ourselves - if not partially - of other countries' experience; on the other side, our best practices in this field can be of interest for other countries.
The percentage of old people (over the age of 65) compared to the working age population has already reached 30% in Italy and - according to current demographic projections by Eurostat - is due to exceed 65% by 2050. While indeed the current birth rate is insufficient to balance the natural change in population and stabilize its structure, the continuous and welcomed improvement in the standard of life and progress in health care provide a distinct contribution to extending the average length of life. In this context, foreign immigration cannot completely counterbalance - in quantitative terms - the demographic gap.
The ageing process is generalized and involves individuals - who live longer, families - with the increase in the number of grandparents and grand-grandparents and the dramatic reduction of children, populations - with the mentioned increase of older and reduction of young people, and subpopulations - with special reference to the declining work-force of age 20-40. Furthermore, since the ageing process is territorially differentiated, the policies to confront it should necessarily be differentiated, and coordinated at national and local level.
The challenge of the population ageing
Despite the often alarming figures involved, changes in the demographic structure should also be considered while taking into account their effects, which undoubtedly lead to both a number of difficult challenges and new opportunities for my country and more in general for all countries.
Let's begin with the challenges involved: the increase in the old population tends to lead to an increase in pension and health costs. If active measures for employment and social protection are not implemented, the sustainability of public finances could be severely affected. A large amount of financial resources have already been transferred from public funds to pay pensions in a number of countries, and this could become unsustainable in the long term if no action is taken.
However, other areas may be affected by changes to the population structure. The health sector is most certainly one of these. The trends for costs in this area are not univocal - due to the facts that services can be made more efficient, and the tools used to control demand can be used more effectively. However the ageing challenge must also involve the sustainability of costs in these sectors - which may have a severe influence on the overall allocation of resources.
Which measures? Extending active life
Our countries have reason to believe that continuous increases in fiscal pressure or indiscriminate reductions in pensions are not appropriate solutions to confronting increased costs of the social security systems: The gap between living conditions before and after retirement would indeed widen, and the risk of old people having to depend on public aid would increase.
Active measures to increase employment and adequate social protection schemes must take into account the extreme complexity of the phenomena and characteristics of the people for whom these policies are designed. Governments must therefore adopt integrated and far-reaching approaches to manage such effects.
The ageing of the population forces us to consider the possibility of extending active life beyond the current average retirement age for those who so wish. However, this must not be implemented using strict frameworks and guidelines, but by creating effective new opportunities to ensure that the expectations regarding lifestyle and career prospects of people are completely fulfilled.
The sustainability of social security systems is strictly linked to the capacity of our countries to fully mobilize the potential of our societies and - above all - to increase the overall level of employment.
All our countries have vast reserves of human resources - deriving from both increased integration of women into the workforce (which is still scarce in many European countries and especially in Italy) and an increase in activity rates for those over the age of 55.
Participation in the labour force currently declines rapidly well before people reach official retirement age (around the age of 65 on average). This is also due to the fact that many pension systems include a number of implicit or explicit incentives to encourage both companies and individuals to early retirement.. In some social security systems, for example, people who work beyond the minimum retirement age receive no real benefits in terms of additional welfare payments.
The capabilities and experience of older people must be fully utilized if we wish to ensure that those over the age of 50 continue to be an active and integrated component of society, and that welfare systems do not encounter increasing financial difficulties.
This requires a revision of all the incentives currently available in pension systems, in order to ensure that working lives are extended: this has became a priority for the Italian Government since 1995, and has led to remarkable medium-long term results. Furthermore, Governments should begin wide-scale experimentation on gradual retirement schemes - in other words those in which people continue to work reduced and re-scheduled working hours and income is integrated with a partial advance on pension.
It should also be noted that until now policy-makers have focussed on regulating the welfare system by trying to delay the retirement of people via new incentives. Adopting instruments which can influence the job supply and consequently encourage the market to offer older people the opportunity to work, is just as important. With regards to this, we think that there is a great need for innovative programmes which extend the working life of people using latest-generation technology capable of relieving the physical fatigue involved in work, and improving organization in the workplace and thereby ensuring that the working life of people is extended while satisfying the needs of older people.
A radical change in managing practices, employment and training policies is necessary to activate older people participation in the job market, to ensure they are adapted to the needs of older workers in the best possible way. Therefore important factors are involved, such as life-long learning, the guarantee of improved safety in the workplace and better protection for the health of employees.
Which measures? The social aspects of ageing - the efforts made in Italy
Over the last few years, the Italian Government has worked towards ensuring a new culture regarding older people - a culture linked to the rights of people in a society in which all ages are important. A society which protects the psychic, physical and social well-being of people by removing as many difficulties as possible and offers appropriate and differentiated services to fulfill specific needs. A society that safeguards independence and encourages older people to maintain their habitual lifestyle as long as possible.
The strategy adopted in Italy concerning ageing as a social problem involves three basic objectives:
o taking advantage of the new opportunities created through the ageing
of people and of the population;
The policies of the Italian Government for older people focus on dealing with the profound changes underway and mainly aim to guarantee older people security, dignity, participation and rights.
Encouraging results have been obtained by implementing the Principles and Recommendations for Action of the International Plan of Action on Ageing endorsed by the United Nations General Assembly in 1982 and the United Nations Principles for Older Persons adopted by the General Assembly in 1991, which provided guidance in areas of independence, participation, care, selffulfillment and dignity.
I would also like to remind the ideas and proposals forwarded at the G-8 Conference of Ministers of Labour held in Turin (10-11 November 2000), which led to approval of a Charter on Active Ageing.
The proclamation by the UN of 1999 as the International Year of the Aged (a society for all ages) generated great interest and positive action in Italy, and led to increased awareness of the topics related to old people and the strategic role they can still play.
One of the effects of the International Year was the approval of a new welfare reform (Italian framework Law 328/2000), aimed at introducing a new strategy for implementing integrated services at all levels - i.e. Governmental and non - with the priority to satisfy the needs of people throughout their lives. This also involves strong cooperation between the public and private sectors, and the significant participation of voluntary and non-profit organizations.
The First National Social Plan 2001-2003 is part of this strategy. The plan implements the general policy law on welfare and involves the strategic objectives and general guidelines for implementing an integrated system of social services and projects to be applied locally.
The objectives and guidelines contained in the First Social Plan aim to ensure a positive vision of old people by acknowledging that the ageing process differs according to the cultural and social contexts in which it occurs. The conditions that express what being old implies differ, as are the related needs.
I would like to remind that 18% of the population in Italy is over 65, that 22% of these are very old, that 34% of all families comprise at least one old person and that 27% of old people live alone - 81% of which are women.
This means that the services and projects offered must be extremely innovative and differentiated, which can be ensured through the creation of synergy and collaboration among Government organizations, voluntary associations and families focussing on vertical and horizontal mutual aid.
Female ageing characterizes mainly the oldest old. The number of women involved increases much faster than that for men: in Italy there are 176 women over the age of 75 for every 100 men. We should therefore adopt specific policies for old women while paying particular attention to equal opportunities.
Although we acknowledge the importance of employment for women to ensure economic, social and cultural growth for our countries, the actual percentage of women active in the labour market is still too low, and over 50% of women over the age of 50 no longer have a job.
This is largely due to problems in conciliating a job with family commitments - almost always the responsibility of a woman. A woman is mother, wife, companion and grandmother, and plays a number of roles throughout her entire lifespan - looking after and educating her children, caring for older family members and other members when they are sick and managing the family budget. However, it is also due to the fact that much discrimination still exist in the workplace. Recent researches show that in Italy 78% of women over the age of 75 have a role as care provider for relatives. Such researches point to a new "older and women-centered family", in which women represent the focus of all health and feeling care activities.
The Italian Government is committed to ensuring that all causes of discrimination are abolished, and thereby providing women means of self-support and independence for later years.
The role of the family
The family in Italy still plays a dominant role in the life of old people. Relationships within the family become particularly important following retirement, which often means fewer opportunities for social contacts. The family thereby becomes the most important element to the quality of life for old people as this is the place in which old people can continue to play an active role while receiving support and - if necessary - a reply to calls for help and assistance. The family undoubtedly still largely ensures assistance to non self-sufficient old people in Italy. The configuration of the family to which old people belong is therefore essential to their well-being.
Italian social policies particularly focus on encouraging the permanence of old people in the family through improvement of all services and projects to support families - above all with regards to caring for non self-sufficient old people:
o qualified assistance at home;
Ensuring that old people can continue to live their habitual lifestyle is part of the cultural choice of a community. Local authorities are therefore considered the real provider of social and welfare services, being responsible for implementing projects identified following an overall assessment of the obstacles and resources, and adopting feasibility programmes to forecast the time, costs, resources, and assessments involved while ensuring that any necessary changes can be effected while such work is underway.
Caring for sick old people at home leads to a substantial change in perspective, i.e. moving from a model in which the sick person revolves around structures providing the services he requires to a model in which structures and professions interact and focus on the sick person and his needs.
We need to recuperate the real, added value of the word "health", and especially so for the "new" kind of patient in our healthcare systems, the frail elderly. Our elderly well know the difference between "health" in its broadest meaning and the mere, classical cure of a medical condition. Health in this sense, in fact, goes much beyond that and entitles the concept of overall quality of life which translates into the highest level of independence attainable, either physical, psychological and spiritual.
The new Italian Sanitary Program (Piano Sanitario Nazionale 2002-2004) poses a renewed and critical attention to preventive strategies. In fact, to the goal of reducing the burden of the most common medical conditions, it emphasizes behavior and lifestyle modifications in such areas as eating habits, physical activity, cigarette use, alcohol consumption, (and drug misuse). It is exclusively through the diffusion of appropriate preventive measures that we could delay the onset of those disabling conditions that would later lead to dependency.
Admission to an acute care hospital is a critical step in whatsoever health care system. Being admitted to an hospital becomes an even more troublesome event for elderly patients, in that it may ensue disability or precipitate an already. existing one, and because of the high risk of incurring a medicalrelated adverse event. It is clear that hospital admission should be considered the option for only a selected group of acute medical conditions, whereas for all the remaining, we should substantially increase the provision of health services at home - either home care-based services or hospitals at home. In this respect, we should be working toward incrementing and redesigning the services at the community level, as requested by the Sanitary Program.
Integration should be the key word at the community level, integration between health and social services. Indeed, frailty is a condition that is typical of the elderly and is best managed in the community, BUT it requires that someone is made responsible for the assessment of each patient' needs and for the integrated provision of services. In some health districts the application of home care services modeled in such a way have been successfully experimented: not only were patients' physical and cognitive function better preserved but hospital and nursing home admissions were also reduced with a consequent economical advantage.
Careful consideration should be paid to the epidemic of Alzheimer's disease. Today, a specific, standard protocol is used across Italy to correctly diagnose and initiate treatment with the newly available medications. This effort has contributed to create a network of medical centers where geriatricians and neurologists are working together to fulfill patients' and families' requests.
End of life care needs to become an issue that has to permeate across our society. Not only certain diseases, i.e., cancer, are increasingly common as we grow old, but also other typical medical conditions of the elderly would certainly benefit of more accurate understanding of all the values that are at stake in the very last moments of life. Preservation from pain but also attention to the emotional and spiritual needs of the patients should become priorities of a modern and compassionate health care system.
All too often, the care of the elderly, even in the most advanced nations, has been tainted by scandals concerning malpractice, denial of care, and abuse. Instead, Governments should instill and nourish the culture of quality. In Italy all the health care services provided for the frail elderly - home care, hospital at home, nursing home, day center, day hospital - are initially submitted to an accreditation process and subsequently, to a constant need of re-certification in order to ensure high standards of quality of care.
The rapidly changing epidemiological scenario - paralleled by the adjustments of the health care system - requires that we consider as irrevocable the need of educating all the professional figures in the game: professional nurses, physical therapists, social workers, and other personnel who is asked to contribute to the proper treatment and care of frail elderly.
Finally, while different institutions are searching what could be considered the more efficient models of care, presently the solution to the problems of the care of the elderly care is "local" and generally, not evidence-based. The identification of innovative and validated models of care at the community level and the standardization of assessment and management seem a worthwhile effort.
The right to economic security
Another widely discussed subject in Italy is the right to economic security - which is essential to ensuring that people can live the last few years of their lives well and satisfactorily.
The economic position of people is one of the primary causes of social exclusion, and above all affects old women who are often forced to "survive" on a welfare pension, and are often in poverty and isolation. In Italy, as in Europe, we note the so-called "womanization" of poverty in old age, which together with disabilities and poor health conditions generates dependence of social services and families and other forms of psychological distress. Older women are indeed the largest number of recipients of welfare benefits.
In this context I would like to remind that recently the we increased the minimum pension to 516.46 euro for all Italians who:
o receive social security and welfare pensions and are over the age
of 70; o receive a pension for the blind;
The Italian Government is also assessing the feasibility of a global social reserve funded by contributions or taxes, which could be based on insurance schemes already implemented in other European countries (such as The Netherlands and Germany) and above all to support non selfsufficient old people.
A welfare mix?
Prevention to ensure a satisfactory physical, psychological and cognitive condition cannot be based on health-related strategy alone. Prevention strategies must also involve a number of initiatives to prevent hardship.
The life of old people is based on a combination of economic, health, psychological and environmental factors that must involve increasing integration between health and welfare.
The change in the number of young people - decreasing - and old people - increasing - in a population must lead to increased flexibility in public spending to ensure horizontal movement of resources and less rigid vertical structures.
Transformation in the structure of families means that they probably can no longer continue to provide the full-time care they currently give. We must acknowledge the protection and support provided by families and integrate this with daily or periodical care by improving and supporting growth in the non-profit and voluntary sectors.
Italy is trying to create a new type of welfare - which we could call welfare mix - whereby the family, voluntary associations and public organizations collaborate to create synergy to lighten a number of problems deriving from the ageing of a population, such as that which can arise from situations involving the combination of non-independence and solitude.
This is the new policy for old people at the basis of the strategy that has accompanied our challenge in implementing actions to develop the support of old people and strengthen family and social cohesion.
Finally, and following to the purposes of the G-8 Charter of Turin, we are convinced that:
o the ageing of our societies will create new opportunities and new
That is why we believe that joint efforts, coherent strategies and improved coordination from all the parties involved both at international, national and local levels can ensure that my country and all countries receive the social and economic benefits deriving from increased activity by old people.