Commentary
Italians are healthy, but the healthcare system can only deteriorate for so long
A seemingly paradoxical situation emerges from all these reports: on the one hand, a picture of impending disaster, and on the other, that of high quality of care and slow but sure progress.
The third annual report from the Organization for Economic Cooperation and Development (OECD) on the status of healthcare in each of its 36 member states has just been published. In the report, Italian healthcare is described as undergoing a structural crisis that is destined to worsen. An aging population is compounded by inadequate funding, a small number of care workers and a very high average age for doctors, at the end of their professional careers, signaling a growing shortage that not even an expansion in recruitment would be able to compensate for in time.
However, even with all these problems, the OECD notes that life expectancy at birth in Italy, an indicator of population health, is over 83 years old, the second-highest in Europe after Spain.
Other interesting reports on Italian healthcare have come out recently. The one published every year by the Gimbe Foundation describes the progressive deterioration in the “health status” of the National Health Service (SSN), the outcome of public defunding, the growth of mutualist health care and the increasing role of insurance schemes, with an increase in direct spending by citizens for the purchase of health services. Gimbe sees the emerging trend as a risk to the survival of the National Health Service because it comes with “over-utilization of low-value health interventions, under-utilization of high-value health interventions, inadequate coordination of care, above-cost purchasing, fraud and abuse.”
As the principle of universalism crumbles, amid increasing geographical inequality, the SSN seems to be losing the trust of citizens and suffering from disaffection among its overburdened workers due to staff cuts and wages below the European average. Thus, the SSN is in a critical condition for its survival and would require radical economic and organizational investment along with a substantial rebalancing of the relationship between the role of the public and the private sector.
In contrast, the report presented by the National Agency for Regional Health Services (AGENAS) provides a scientifically rigorous report on the performance of the National Outcomes Plan (PNE), a project that assesses the performance of all Italian hospitals.
The picture that emerges from this analysis is not entirely rosy, but it is marked by cautious optimism. The indicators measured show a trend towards improving in all areas surveyed, despite the presence of inequalities, sometimes very significant, among the 1,363 hospitals analyzed, between different geographic areas of the country, between men and women, and between subjects of different nationalities. The treatment of heart attack and that of femur fractures has been improving, the treatment of some tumors has been improving as well, and there has been a drop in the use of cesarean section as a mode of delivery.
A seemingly paradoxical situation emerges from all these reports: on the one hand, a picture of impending disaster, and on the other, that of high quality of care and slow but sure progress. None of these perspectives are biased and none of them are wrong: the structure of the public and universal health service appears solid enough to withstand defunding and neglect for a long time, but the crisis is already underway and can be clearly seen when looking at inequalities. Both in the availability of services and in the quality of hospital services, the common factor is territorial and social differences that in effect nullify the universal aspect, turning the right to healthcare as arising from citizenship into a dead letter.
The apparent contradictions between the reports have to do with the difference in their perspectives: the Gimbe and OECD reports focus on the organizational and operational parameters of the Health Service, that is, they start from a macro-level approach of process evaluation and describe a machine working at the limit of available resources, which continues to function by sacrificing an important part of its tasks. They accuse the shortage of “fuel” for the machine, but never criticize its model. By contrast, the PNE report, with a micro-level approach, focuses on a subset of specific healthcare services whose quality it assesses at each individual hospital, not looking at their impact on the health of the population as a whole.
The former approach, paradoxically, can end up bolstering a system that expands the supply of services without leading to improved health, while the latter risks promoting a system that deals only with those who come in to use it, regardless of the share of need that remains unmet.
Both approaches describe reality within their own scope, but in both cases, this is a reality that does not consider the health of the population and whether its needs are met. Instead, the revitalization of the National Health Service as a guardian of rights – and not only as a provider of services – should be founded precisely on the relationship between the functioning of the system, the health of citizens and its equitable distribution. This is a particular duty incumbent on those who are governing the country, who have shirked it so far.
Originally published at https://ilmanifesto.it/salute-un-diritto-negato-quello-che-i-rapporti-non-dicono on 2024-11-20