Not even the pandemic was enough to convince those in power in Italy to invest in public health. After the increase in resources brought about by the emergency, and despite the NRP, investment in public health in Italy will fall once again over the coming years.
That is the highlight of the Fifth Report on the National Health Service, the snapshot of our health care system presented on Tuesday in the Senate by the Italian Group for Evidence-Based Medicine (GIMBE).
The numbers are unforgiving: over the decade 2010-2019, the increase in the National Health Resources fund, the fund made available by the government to the regions responsible for managing health care, was just €8.2 billion in absolute terms. That amounts to +0.9% per year, while inflation was growing by 1.1%: in real terms, equivalent to a cut.
The comparison with other industrialized countries is even more dispiriting: in 2008, all G7 countries (excluding the U.S., because their model based entirely on private insurance is not a good object for comparison) invested between $2,000 and $3,000 per capita in health care. In 2020, the only country that failed to reach €3,000 per capita was Italy. Other countries, such as Germany, have doubled their investment in healthcare and are now close to €6,000 per capita.
Then came COVID. GIMBE’s analysis shows that measures taken during the pandemic raised the National Health Resources fund from €113 billion in 2020 to €124 billion today. In the meantime, however, inflation has again reached the kinds of rates seen in the last century, cutting the value of the additional money. Moreover, of the €11 billion added in these three years, half came from the COVID-19 decrees and are not structural to the system.
Therefore, health care will not emerge strengthened from the crisis: as confirmed by the update note to the Economy and Finance Document drafted by the government, public health spending at the end of the next three years will fall to 6.1% of GDP. This is even below pre-pandemic levels. In terms of per capita public spending, Italy remains below the OECD average (€3,052 versus €3,488). Among the G7 countries, Italy is at the bottom.
The extraordinary investment of recent years has already been eroded by the COVID-19 emergency. “The pandemic has not let up at all,” reads the GIMBE report, “and it is beginning to show its medium- to long-term effects, showing itself as not only an ‘acute relapsing disease,’ but also as another chronic disease that worsens the health status of the national health system.”
The symptoms are well known in the health system: lengthened waiting lists, new needs in response to Long Covid and mental health, and, most importantly, health staff looking forward to exiting the system altogether. There are countless early retirements, cases of burnout and transfers to private health care that leave emergency rooms unstaffed and job competitions without applicants. The higher number of places in residency schools and regional courses for family physicians will bear fruit only in a few years.
In the meantime, there is greater demand to be addressed with fewer resources. The strategy with which the regions will try to get out of this is also already known: “Service cooperatives, recruitment of retired doctors and calls for doctors from abroad,” explains GIMBE president Nino Cartabellotta. Outsourcing medical and nursing services allows salaries to be shifted to the “acquisition of goods and services” budget item, at a higher cost to the taxpayer and with higher precariousness for professionals.
In addition to the scarcity of resources, the threat of the differentiated autonomy wanted by Lombardy, Veneto and Emilia-Romagna hangs over the health service. If the Meloni government approves it, autonomy will widen the gap between one region and another. While the three regions intend to remove the cap on hiring (a great idea, but one that should also be extended to the others), they are also asking for more autonomy in introducing supplementary health funds – which means bringing back private mutual healthcare funds.
GIMBE calls this project “frankly subversive,” as it would “give free rein to regional mutual-insurance systems totally disconnected from the – albeit fragmented – national legislation,” would sanction “a competition between regions, with the transfer of personnel from the South to the North,” and would represent “a death knell for collective bargaining and for the unions themselves.”
