Gianluigi Trianni
Public health, the NHS, in Italy is already differentiated by region. The failure of this differentiation is evident and it is irresponsible to accentuate it as foreseen by the bill on differentiated regional autonomy (for convenience DDL Calderoli). Differentiated regionalism prefigures regional taxes and the withholding of taxes on a territorial basis, breaking any idea of equitable distribution of resources (read here)
With the approval by the Senate of DDL no. 615 on differentiated regional autonomy (for convenience DDL Calderoli), January 23rd was a Black Tuesday for the National Health Service, for Health and for the Republic. (1) It won’t be the last, rebus sic stantibus. The Meloni government and its majority are in fact proceeding with the parliamentary process of Autonomy, despite the public opinion being over 60% against it. Public health, the NHS, in Italy is already differentiated by region. The failure of this differentiation is evident and it is irresponsible to accentuate it. This is demonstrated by consolidated healthcare and management data.
In 2018 the standardized avoidable mortality rate per 100,000 inhabitantsan indicator of quality and effectiveness of care, has fluctuated from 14.8% in Trentino-Alto Adige to 20.8% in Campania. (Figure 1)
Figure 1. Avoidable mortality (see note) per 100,000 inhabitants
Use: Avoidable mortality:
Mortality treatable: causes of death that can be mainly avoided through timely and effective healthcare, including secondary preventionPreventable mortality: causes of death that can be avoided mainly through effective public health intervention and primary prevention
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In 2019 the provision of the Essential Levels of Assistance (LEA), the LEP (Essential Performance Levels) in Healthcare, mandatory for all Regional Health Services, fluctuated from 93.4% in Emilia-Romagna to 56.3 in Sardinia. In 2022, operational efficiency measured with combined indicators fluctuated from 59% in Veneto to 30% in Calabria. In 2020, public health spending per capita fluctuated between €2,715 in Valle D’Aosta and €1,942 in Campania, with a difference of €773 per capita. Also significant is the fact that private spending at the same time went from €987 per capita in Valle D’Aosta and €406 in Campania, with a difference of €581.
The organization of the NHS in the various regions is also different. The most important case, because it is a precursor and emblematic of the creation of the healthcare market in Italy pursued by neoliberal policies and parties, is Lombardy.
Lombardyin fact, it is equipped with territorial social and health agencies (ASST), exclusively providing services in competition with private companies, and health protection agencies (ATS), exclusive holders of supply agreements/contracts with public and private providers. The contrast with 833/78 of this public health organization imposed by Formigoni with LR n.33/’09 and renewed by LR 22/’21), guiltily accepted without opposition by the Draghi-Speranza government, is clear. Starting from the centralization of purchasing functions and/or territorial areas of assistance and without enumerating all the typologies here, it can be seen that there is no region that has a healthcare organization that is the same as that of another.
The same employed professionals are “locked up” in “salary cages” with different remunerations between regions and between healthcare companies. Over the years, in fact, the “salary bill” has been differentiating between the regional health services, and within them between the companies, due to the succession, contract after contract up to that of last year’s sector, of increases as a percentage of the historical and not “by capitation”, in addition to the different use of the institution of “sharing. Added to this are the so-called “recovery plans”, i.e. the forced freeze on all expenditure in the event of a deficit equal to 7% compared to the public finance objectives established on the basis of the “European Stability and Growth Pact”, established in 1997. .
With the Calderoli DDL, the majority and the Meloni government, however, began the transformation of the current mere differences in administrative efficiency of the regional structure of the NHS in healthcare, into a social calamity for citizens. In all regions, not only in the South, but also in the Center and the North. The regions, all of them, both ordinary and autonomous, will becomeregional agents” of the dismantling of the NHS and the progressive privatization and financialisation of healthcare in Italy. (2) A “decentralized and autonomous regional path” to neoliberalism, in short, through the subversive “balkanization” of the Republic and its regional administrative structures.
Those who will suffer first and foremost, both employed and non-employed workers and professionals, who in all regions, without distinction between North, Center and South, are not in the very high income bracketsand will have to give up treatment or the high costs, which increase year after year, of insurance policies and/or access to direct payment treatments (out of pocket). This is confirmed by the combined provisions of the 2024 Budget Law, the Calderoli DDL and the 2024 Milleproroghe Decree. The 2024 budget law allocated approximately 131 billion euros for the National Health Fund (FSN), 10 less than the 141 billion estimated with no increases for 2022 other than those for cumulative inflation, which was 9%. In 2024, regardless of the amount of inflation that will be recorded at the end of the year, the FSN will therefore be even more insufficient to finance the NHS. And the fragmentation into 19 Regional Health Services (SSR) plus 2 Provincial will not help to solve this problem, not even for the Northern regions.
The Calderoli DDL is clear: the LEAs/LEPs are financed within the “limits of the resources made available in the budget law” (art.4) and “new or greater burdens on public finances” are excluded. (art.9). Devolution or not, the ones who will have to cut public services and privatize them will be the Regions and also the Municipalities, which on a political level, in any case, and sometimes also on an institutional level (Territorial Socio-Health Conferences), are involved in the planning of health services . Finally, the Milleproroghe 2024 decree will not delay the devolution in healthcare both because the LEAs are already in force with the Prime Ministerial Decree of 2017, which updated them, and because the Ministerial Decree of 01.23.2023 on tariffs has been in force since 01.24.01, and because the FSN, in fact, finances them, although far below what is needed.
As soon as the Calderoli DDL becomes law with approval in the Chamber, for Veneto, Lombardy and Emilia-Romagna we will start again from the pre-agreements of 2018 and 2019 (art. 11), and Healthcare has been requested in practically the same form by all and trAnd. (Table 1).
Table 1
Furthermore, from the same moment, the three regions could obtain autonomy in the nine subjects not bound to the LEP. Among these is the subject of “professions”, which in healthcare means the field of medical associations and other professions. (3) The remaining regions will only have to adapt or ignite political-administrative conflicts with the State and/or among themselves. With the Calderoli DDL the attack on health will be much more extensive than the direct and specific attack on the NHS alone, since the “protection of health” it is pursued first of all by adopting primary prevention as a binding guiding criterion in all policies, and therefore in all other “devolving” matters. One at random, the environment! But if you look closely, directly or not, so do all the others
Hence the logical need to oppose differentiated autonomy “in toto”, not to limit ourselves only to asking that healthcare be extrapolated from it. The implementation of differentiated autonomy, linked to the premiership, is in full swing. Government and Parliament “don’t listen to reason”. The opposition of the political, social forces and of a large part of the associations is without results: their perception/cognition of the subversive gravity of the political process of “democracy” in progress seems very limited, hence the absence of conviction and incisiveness political acts.
Hence the need to relaunch trade union and social struggles, to ask the Regions to submit the appropriate appeals to the Constitutional Court and, above all, to hold a referendum. (4)
Gianluigi Trianni, Public Health Doctor.
References
Viesti, The mini-secessions, bomb in the silence – Il Fatto Quotidiano 24.01.23Trianni, A Gazzetti “Privatocracy” and Healthcare in Italy Privatisation, Capital Concentration and Financialisation – Work and Health n. 6 23.06Simonetti Autonomy in healthcare: what is expected and what already exists – Il Sole24ore Healthcare 23.02.06Villone. Regional autonomy the road is the Consulta – La Repubblica 01.24.24
International health systems Differentiated autonomy, Calderoli DDL, Financialization, Meloni Government, LEP (Essential Levels of Performance), Essential Levels of Assistance (LEA), Avoidable Mortality, Privatization, differentiated regionalism in healthcare, National Health Service (NHS), dismantling of the SSN