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

Abstract

At the time of its inception, in 1978, prevention and primary care were set as fundamental pillars of the Italian National Health Service (NHS), emphasizing the collective and social dimension of health. These principles were progressively neglected over the following four decades. Marketization, managed competition and managerialization privileged the individualized, highly specialized healthcare services mainly provided in hospitals, to the detriment of local outpatient and primary care services. After 2008-09, austerity policies exacerbated this situation determining under-financing as well as structural and staff shortages, while increasing tensions arose between the central government and Regions in the decentralized NHS. In 2020-21, the pandemic highlighted these critical issues. The need to develop a universal and strong outpatient, primary and community care system became evident in order to ensure the appropriateness and quality of foundational health services. This requires the State to play a more prominent role in the NHS governance.

The Fate of Social Modernity

“…This bias persists in many places even as welfare state entitlements have not kept pace with evolving needs, given an ageing population, rising rates of co-morbidity and the increase of non-communicable diseases -that is, an increased number of 'people living with limitations in functioning' (Stucki et al 2018: 312). This is consonant with studies about the recent development of healthcare in general (see Stuckler et al 2017, Böhm 2019Bifulco and Neri 2022;Krachler et al 2022). As Greve (2020, chapter 8) has shown, once outlays are weighed against assumed needs per person (that grow with population ageing), healthcare expenditure decreased in the years prior to the outbreak of the Covid-19 pandemic, along with a surge of out-of-pocket payments and a reorganisation of the healthcare infrastructure.…”

“…A 'separation between planning and execution' (Gasparre and Bassoli 2020: 945) has added to the entrenched 'lack of integration' (Casanova et al 2020: 1) within the entire universe of social and medical services. Various regions have introduced tools of managerial governance (outsourcing, contracts with non-state providers, lump sum payments to hospitals) into the LTC system and its environment, which tend to induce greater fragmentation within the wider human service infrastructure for elderly people (Bifulco and Neri 2022). While EU funds have contributed in some places to sustain local projects, access to publicly orchestrated domiciliary services has become altogether more difficult in recent years.…”