Economic Crisis, Decentralisation and Health Inequalities: The Case of Italy

Abstract

The chapter describes the recent evolution of the Italian National Health Service (NHS), highlighting the potential and effective consequences of the economic and financial crisis on social and territorial inequalities, especially in terms of service access and quality. First, it analyses the cost-containment and austerity policies in the NHS, which brought to a relevant underfunding of the public healthcare system, comparing public expenditure trends in Italy with those of other Western European countries. Then, it stresses the increasing role played by private expenditure, emphasizing the risks in terms of health inequalities connected to the high level of out-of-pocket payments and to the spread of the occupational funds. Finally, a reconstruction and analysis of the current changes in the NHS governance is carried out, explaining in details how the reassertion of the role of the Central State in health policy entails different consequences for different areas of Italy, widening the territorial inequalities and increasing the North-South divide. So far, these changes have taken place without any structural reform, in an imperceptible but progressive way, which does not help to develop an appropriate and necessary debate on the future of the healthcare system. 2As a result, the NHS is structured on three levels: a national level, constituted mainly by the Ministry of Health; an intermediate level represented by the Regions and their Regional Ministers and health departments and a local operational level, directly accountable to the Regional one, made up of about 70-75 Aziende sanitarie ospedaliere (hospital trusts, henceforth HTs) and about 135-140 Aziende sanitarie locali (local health authorities, henceforth LHAs).Since 2001, no major reforms have been introduced into the NHS. However, important changes have almost imperceptibly taken place, connected the economic and financial crisis, which are weakening the universalist nature of the NHS.This chapter will analyse the evolution of the NHS in Italy during the last decade, hence in the years of the crisis, focusing on some trajectories of change underway, mainly in the health expenditure and in the NHS institutional framework governance. These trends might have important consequences in terms of service access and quality, increasing the traditional social and territorial inequalities and hence weakening the universalistic nature of the NHS.

Public-private partnership in health care organizations. How to cope with complexity issues: a comparative case-study between Italy and the US

“…To identify the areas of complexity, which we outlined above, we conducted a literature review. Using the Scopus database, with more than 20,000 peer-reviewed scientific journals listed (Brown, 2020; Fanelli et al , 2020; Mishra et al , 2017), we collected related literature. We conducted a Boolean research based on keywords: “Public Private Partnership” OR “PPP” AND Healthcare* OR “Health Care” OR “Hospitals.” To identify the area of major concerns, we defined what were the most recurrent keywords present in the literature, excluding keywords on non-related issues (e.g.…”

“…The I-NHS was founded with the guiding principles of universality, equity and solidarity (Signorelli et al, 2017). Yet, in the wake of the 2008 financial crisis, the I-NHS had to make cuts to public health expenditure across each subsequent government (Ferrario and Zanardi, 2011;Neri, 2019) and raised concerns over the quality of care provided (Falco, 2019). Furthermore, the COVID-19currently ongoingpandemics revealed the weaknesses of the system, suggesting potential issues to be faced .…”

The Italian National Health Service: Universalism, Marketization and the Fading of Territorialization

“…In connection with under-financing, the NHS suffered from an increasing lack of human and structural resources. In particular, staff shortage has become evident over the last decade, as highlighted also by specialized literature (Vicarelli, Pavolini, 2015;Neri 2019a;2019b); this and other dimensions of the NHS under-resourcing were destined to emerge significantly during the pandemic.…”

‘Intended’ and ‘unintended’ consequences of the privatisation of health and social care systems in Italy in light of the pandemic

“…Since 2007, all nine southern and centralsouthern regions (excluding the small region of Basilicata) have been involved in a recovery plan, compared to only two out of the 11 northern and central-northern regions. As regions subject to and those not subject to the recovery plans have very different levels of autonomy in health policy, the implementation of this mechanism has de facto introduced a sort of 'differentiated health-care federalism' between Italy's north and south (Frisina Doetter and Neri, 2018;Neri, 2019aNeri, , 2019b.…”