London 2001 Conference Abstracts: G. Barro et al

Giovanni Barro, Antonello Briguori, Mara Giglioni, Rita Manfroni, Maurizio Mori, Osvaldo Palumbo, Carlo Romagnoli, Elisabetta Rossi, Stefania Piacentini

Micro and Macro-privatisation are obscuring the sky of the italian National Health System

Equi.Jus Association, Perugia
Regional Health Service of Umbria

A national health service (SSN) was applied in Italy in 1978 with the law 833. The British NHS was its model.
It is not only a curiosity to observe that the law 833 was endorsed just a few weeks after the Alma Ata Conference, when the strategy of WHO, pushing for the priority of primary health care within a public health service, was flourishing.


This coincidence of dates reflects two separate itineraries followed in autonomy but with reciprocal influences. Indeed the law 833 was the conclusion of almost a ten years period of struggles for health, promoted jointly by the Trade Unions, the most important democratic parties, the most advanced scientists, even in the academic settings, the womens� movements and the strongest Unions of doctors (hospital doctors and GPs). Such a large movement drew its nourishment from the WHO�s activity and documents against the current concept of medicine as an ensemble of practices pivoted on highly specialised care, and its organisation as the triumph of the hospital. (At a few weeks from 7th April, devoted this year to mental health, it is not to be forgotten that 1978 is also the year of the Italian law which abolished mental hospitals, a law strongly fostered by Franco Basaglia).


Notwithstanding such a smart �birth certificate�, the SSN did not grow up so smartly for many reasons, among which a major role must be assigned to the end of the political coalition that had brought the law into effect, a coalition pivoted on the so called national solidarity and ended after the assassination of the premier Aldo Moro by terrorists.
After the breakdown of the national solidarity, the conservative parties became more and more influencial, playing an always stronger hegemony on those social and political sectors who, having refused the reform in 1978, were now trying to frustate it either (a lobbystic minority) through an open opposition, or (and mainly) bridling it in the web of a centrally-run policy and underfinancing the expenditures. Again, it is not a mere curiosity to observe that during the period under consideration many health ministers were drawn by the liberal party, the sole democratic party to vote against the reform in 1978.

After 1978 the Law 833 has been reformed many times, with the consequence (maybe desired) to prevent its full enforcement. Major changes to the Law 833 were introduced in 1992 and 1999.


The first one is the law n. 502 which aimed at rationing the health system and giving it more efficiency. Both such targets were inspired by the reform adopted in the UK by Margaret Thatcher: we can cite as an example the establishment of trusts for running USL and hospitals, the appointment of managers as general and sole directors of such trusts, the creation of a quasi-market for the trade off of the medical procedures, even when delivered in a public framework, and other such measures. None of them obtained more efficiency, the only result being to strengthen instead of weaken hospitals versus primary health care and territorial services. Nor has the objective of a control over the expenditure�s trend been attained, which continued to expand notwithstanding the large number of measures undertaken in order to reduce the costs of the service at a local level.


Beside that, the Law 502 resulted in a huge quantity of severe contradictions, first of all the multiplication of medical acts, not always based on health�s needs, and viceversa the loss of effectiveness in the preventive and prevention�s domain.


In 1996 a new government was appointed, based upon a left-center coalition, with Mr. Prodi as premier and Mrs. Rosy Bindi as health minister. A new reform was then planned to cope with the more dramatic consequences of the law 502, which came into effect in 1999.


At the end of the day the period from 1978 through 1999 can be divided into three phases. In the first one (lasting until 1992) we had practically no health policy because our system was paralysed from economic and financial measures and by the related under-dimensioning of expenditures.


The second phase (until 1996) coincided with the arrival in Italy of the long wave of American neoliberism: many attempts of health policy were carried out, but their sign was opposite to the welfarian principles of the 1978 reform.
The third phase, still lasting, is characterised by the attempt to reset the system and its welfarian principles through the adoption of measures aimed at rectifying the most severe bias of the previous policies and at recovering many of the basic principles which had been lost along the way.


As a final statement it can be sinthetically affirmed that in comparison with other western european countries our health system could cross the neoliberist wave of the Nineties and the related reaganian policy saving enough of its welfarian characteristics, except for some limited, even if consistent, losses of universality and solidarity (the same unfortunately cannot be said for equity).


We must therefore complain that some measures adopted in 1999 after the demands of the doctors contracted to the SSN, and the measures recently adopted by some regions ruled by right-center majorities, have darkened the horizon.


For a better understanding of this point, it must be recalled that the doctors contracted to the SSN are allowed, since 1978, to practice medicine publicly as well as privately, in the second case for payment. Such a liberal profession can be practiced both inside the public structure and within private clinics and hospitals: this faculty, not accompanied by strategies assuring the priority of the doctors� duties in favour of the public service, provoked a veritable concurrence against the pubblic service, stemming the paradox that doctors are allowed, by their employers, to become their competitors. The reform adopted in the early 1999 has not abolished the right for doctors to legally work privately, but has obliged them to chose just one form of liberal profession, intramoenia or extramoebia, which means inside or outside the public hospitals. In order to make an option which is not so good in terms of mere earnings desirable, new incentives have been introduced in favour of those opting for intramoenial activity.


Unfortunately the application of this law has been affected by a pause. The terms for applying the new regulations have been considerably diluted, the fulfillment of the option delayed and the incentives quite amplified by some hospital administrations. The new minister of health (Prof. Umberto Veronesi, a well known oncologist from Milan), justified such measures assessing that the public hospitals are not yet ready to lodge the liberal profession intramoenia. Whatever the real reason, it is a matter of fact that as of few months the atmosphere inside the public hospitals is worsening and even darker clouds are pending.


Waiting lists are considerably lengthening, and the citizens are often forced to pay out of pocket if they want to be cured in a timely manner. Nowadays a cospicuous part of the hospital�s activity is practiced for payment and not free of charge as requested by a public health system worthy of this name. In Perugia, which is all but the worst place in Italy for equity and fairness, many departments, especially in the surgical areas, operate free of charge only for emergencies and oncology, the remaining requests being delayed even for many months, or alternatively offered for payment when a timely service is necessary, including the case of some preventive procedures (i.e. mammographies and cervical examinations).


But another severe consequence is the creation of caregiving areas directly managed by doctors for their liberal profession with the creation of clinics only nominally public, but in fact private, where to select the patients who can pay out of pocket and to absorb a huge quantity of professional, technological and therapeutic resources that should be equally distributed among all people: a consequence even more dangerous because its effects are likely to become more lasting.


Such a tendency, that can be defined a "microprivatisation", must be taken into consideration in parallel with a hidden process of "macroprivatisation". Indeed, many fear that our hospitals will be transformed from public trusts, as they are now, to corporate holdings, owned by both public and private stakeholders, with the creation of healthcare areas reserved to the well-off, destroying the equalitarian profile of the SSN.


Elements of this trend are already noticeable in Lombardia, a Northern region administrated by a centre-right majority and bridgehead for a very large devolution destined to disintegrate the country�s unity, the central state being empowered only for a very limited span of topics. The health system that Lombardia wants to build in its territory and then to transfer all over the country is indeed based upon a complete parity between public and private providers, a strategy inspired to the Thatcher split between providers and purchasers, but much more flexible as far as the control on the performances� quality and quantity and on the expenditures is concerned.


After that or because of that, the expenditure for hospital and specialistic care is growing more quickly in Lombardia than in the whole country. For instance, the per capita cost has grown 25% in Lombardia and 19% in Emilia (a left-ruled region where the reform has always been correctly enforced). The main role for this trend is played by hospitals: in the last year Emilia reduced its admission rate 5% versus 3% of Lombardia.


The regional government of Lombardia is all but worried by this result, because its actual scope is far more bursting than a �simple� rationalisation. Lombardia is the largest region for population, and the one where Berlusconi and Bossi are installed. It actually wants to trigger a process of public health system dismantling and healthcare privatising and marketing, no matter if the quality of the service will worsen and expenditures increase.


The final point envisaged from the supporters of this policy is to abandon the welfarian system based on universalism, and to replace it with a �Bismarck model�, not to say a USA system. The issue of this perspective is partly consigned to the result of the next general elections, when the country will decide the destiny of the Welfare state. The neo-liberal strategies, up to now substantially rejected, have been included in the electoral agenda of the centre-right coalition. Its victory would mean the rejection of a fifty year history of social security, including 22 years of a welfarian health care system.