Barriers to Reforming Healthcare: The Italian Case
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- Adinolfi, P. Health Care Anal (2014) 22: 36. doi:10.1007/s10728-012-0209-0
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Using the conceptual lenses offered by the ideational and cultural path taken in the health care arena, this article attempts to explain the trajectory of recent major health care reforms in Italy and the reasons for their failure, as well as providing some directions for successful intervention. A diachronic analysis of the relatively under-investigated phenomenon of health care reforms in Italy is carried out, drawing on a systematic review of the Italian and international literature combined with the research work carried out by the Author. For all the three major health reforms examined, a significant gap between the authoritative policy choices taken and the overall implementation, in terms of process and system changes, can be observed, determining a growing distance between the theoretical efficiency and the practical effectiveness of the Italian National Health Service (NHS) as well as its detachment from the social system. The main obstacle to effective reform seems to be the cultural hegemony of the administrative-managerial and the biomedical paradigms, which, by reinforcing one another, yielded infertile ground for renewing in a post-modern sense the Italian NHS. The various Reforms have not been conceived to break such a positivistic monopoly in that they did not promote cultural or educational intervention. In this context, intervention that acts at a cultural level, such as reforming university education for physicians and managers or devising immigration policies to attract adequately acculturated people to the Italian NHS, seems to be the most promising.
KeywordsPositivismHealthcare reformUniversalistic healthcare systemManagerializationClinical governanceBiomedical modelAdministrative paradigmItaly
Evidence Based Medicine
Educazione Continua in Medicina
Diagnosis Related Groups
Italian National Institute for Statistics
Local Health Unit
National Health Service
New Public Governance
New Public Management
World Health Organization
The Italian National Health Service (NHS) has gained a worldwide reputation as an advanced healthcare system since being ranked second in an international Classification of Health System Performance, published by the World Health Organization.1 However, despite such commendable achievements, Italy has scored quite badly in the Health Consumer Powerhouse Report and Consumer Index,2 which measures and ranks patient-perceived performance of healthcare systems.3 The discrepancy between the experts’ conclusions in the WHO Report and the public opinion, is linked to a growing gap between the formal principles and structure of the Italian NHS, and its effective functioning and performance. Despite the various reforms carried out during the past half century in the Italian NHS, a sharp contrast undoubtedly exists between the formal architecture of an advanced system centred on health promotion, community services, integrated care, and the substantial reality of a hospital-centric, specialistic, pharmacological, fragmented health system, sharply detached from society.4 In spite of universal coverage, citizens appear to rely more on their own financial resources for health care.5 This contrast also applies to the egalitarian spirit of the celebrated ‘homogeneous levels of assistance’ (national standards relative to the minimum levels of Health Services that the NHS has to guarantee to all citizens) and the accentuated disparities in Health Services, as measured by data on inter-regional patient movements as well as on health outcomes (such as the infant mortality rate6) which reflect deep-rooted inequality in Italian society. Furthermore, there is a marked discrepancy between the managerial façade of health care organizations, and their bureaucratic dynamics.
The gap observed between theoretical efficacy and practical effectiveness poses the question of how this can be explained.
In our previous study7 we have shown that in Italy, since Ancient Times, medical-health models have been largely influenced by positivistic ideas, which combined in various patterns and reached a peak in the modern era, resulting in the biomedical model, which has dominated healthcare for 300 years. An interesting study by Raphael, Curry-Stevens and Bryant8 pinpoints specific barriers to implementing an effective health promotion system, where an important role is played by the epistemological dominance of positivist approaches to the health sciences.
In the light of these considerations, it would be legitimate to hypothesize that a positivist approach could have affected the dynamics of health care reforms, and in particular, could have impeded the implementing of an effective health promotion system in Italy, thus explaining its evident shortcomings.
Research Design and Method
Before dealing with the issues identified, some specifications on the concept of ‘positivism’ are required. Positivism relies on the belief that a naturally ordered external world exists independently of human interpretation, and that objective knowledge about the world can be acquired through direct sensory experience. Human beings are conceptualized as external actors capable of controlling and dominating natural phenomena. This extends beyond the relationship between Man and Nature to the relationship between Man and Society and to general human interaction (including private care relationships). From an epistemological point of view, positivism is dominated by the ‘principle of separation’, according to which the knowledge of the basic elements—not the totality—of the physical and biological world is fundamental, and by the ‘principle of reduction’, according to which, in order to solve complex problems, it is necessary to reduce them to simple elements. Such principles lead to the detachment between the object of observation and the observer, the isolation of objects from their environment and their independence, and create barriers and boundaries among disciplines, producing, in particular, a fracture between science and philosophy, or, more generally, between scientific and humanistic knowledge. As regards the anthropological conception, a positivist approach considers the two human dimensions—somatic and relational—as separate and independent. With reference to the medical field, positivism leads to a reductionist focus upon cells and bodily organs on the part of researchers of biomedicine and a focus on behavioural risk factors (lifestyle) on the part of researchers of health science.
When considering the positivist tradition that characterizes Italy, the research question that arises is twofold: to what extent and why have the reforms of the Italian health care system been impeded by the positivist heritage, and what implications can be drawn more broadly in terms of providing a framework for intervention.
To deal with the above research questions, a diachronic account of the Italian health care reforms is required. While, as Ongaro9 points out, there is an abundant harvest of empirical evidence on health care reforms and on the reforms of the public sector in general as regards the Anglo-American world, particularly the countries where New Public Management originated (such as Australia, New Zealand, United Kingdom, USA and Scandinavian countries), other nations, including Italy, have to a certain extent been neglected.10
As regards the sources used for the analysis of health care reforms in Italy, a systematic review of the relatively scarce Italian and international literature has been combined with the research work conducted by the Author in a number of projects on the Italian health care system in which she has been involved for the last 20 years. The research has produced an edited textbook,11 articles in journals,12 and some book chapters,13 and has enabled the Author to confront the significant ‘test’ of how models and hypotheses resonate with the experiences of key actors of the healthcare reforms.14
Administrative reform is the artificial induction of an administrative transformation, against resistance. It is artificial since it is produced by Man, deliberated and planned […]. It has moral connotations, since it is initiated with the conviction that results are better than the status quo and worth the efforts to overcome resistance.16
This interpretation leads to the difficult task of measuring the final results of reforms in terms of improvement. Resorting to the definition of process and system changes employed by Pollitt and Bouckaert,17 the structural changes that occur to the health sector as well as the changes in the process through which health care organizations are run, can be considered as the intermediate but significant effects of health care reforms.18
In analyzing reforms which appears to have had both positive results, at the level of authoritative decision making in some specific areas, and negative results, at the level of the structures and processes of health care determined by its implementation, as emerged from our previous study,19 the reforms are conceptualized as a policy domain, articulated in the two distinct phases of decision and implementation.
In this framework, considering as starting point the mutualistic system developed in Italy after the First World War, three major policy cycles are identified in the health care sector during the second half of the twentieth century: one enforced during the period 1978–1992, the second during the period 1992–1999, and the third starting in 1999. For each, both the results of health care reforms in terms of policy decisions and the results in terms of process and system changes are outlined, thus encompassing the whole policy cycle.20
Due to space limitations, the analysis is limited to the aspects which appear more significant to the purpose of highlighting the influence of positivist approaches, while other aspects, ranging from the political-electoral system to the institutional setting, are not considered. Similarly, a simplified account of the reforms is proposed, which shows their trajectory as linear and straightforward, neglecting the many attempts at reforms taking place in between the two extremes of the trajectory. Recent years are not examined, since the distance from events is too short to allow for a detached and unbiased evaluation.
The Social Health Insurance System
During the early twentieth century a social insurance system of healthcare was established in Italy, similar to that of the other Western European countries. A large number of occupational schemes, administered by a variety of independent agencies, provided cash benefits and direct health assistance through contracts with doctors, hospitals and pharmacies.
The system was inspired purely by a perspective of health insurance rather than health promotion, detached from the socio-environmental reality of illness and health. Hospitals were the lynchpin of the healthcare system: their articulation in relation to the academic disciplines, and organisation in compliance with the bureaucratic-hierarchical model, favoured the development of medical knowledge, but promoted a focus on diseases rather than on patients, perfectly in line with the biomedical model that had gradually been gaining ground.21 This was functional to the pursuance of specialization and research objectives, and explains the dehumanizing characteristics of hospitals: shoddy reception procedures; scarce attention addressed to patients; poor and confusing communication; fixed visiting times and bare and uninviting rooms; no daytime recreation spaces; daily schedules upsetting social synchronies and provoking changes in the ‘circadian’ rhythms regulating cell chrono-biology, as well as a lack of familiar reference points or evidence of reassuring daily routines to keep the patients occupied, both in a biological and psychological sense, to distract them from existentialist anxiety.22
On the whole, the mutualistic experiment has paradoxically been both vehemently criticized and highly praised. What for some experts was an appreciable articulated national system, for others was a bureaucratic system showing scarce sensibility towards community and environmental illnesses, with often inappropriate medical outcomes;23 in the same way, what was considered the celebrated extending of solutions to the population’s health needs, for some commentators was nothing but the hypertrophy of “a privileged object of sub-government”; similarly, while some scholars underline how the system had contributed to reducing the gaps between the poorer and the wealthier classes as regards health, at the same time others highlight how the exclusion of the unemployed or under-employed hit precisely those categories of citizens needing greater levels of protection; what for some scholars was considered a positive adapting to the specificity of the Country, for others was nothing but pursuing particularistic interests.24
Rather than embarking on an evaluation of the experience, our aim is to highlight its position with respect to the cultural coordinates of reference. The two pillars on which the social insurance system was based were, in effect, ‘the biomedical model’, with its faith in ‘scientific medicine’, and the ‘bureaucratic paradigm’, with its pervasive regulations and functional specialization. The former, as noted above, was perfectly in line with the positivist notion of Man and his relationship with the natural world. The same applies to the latter: on the one hand, impersonal rules and formal procedures, aimed at limiting variance and reducing complexity, meant the possibility of a total control of the organization, thus mirroring a positivist vision of the relationship between Man and his external environment, while, on the other hand, the predominance of functionalism and the parcelling out of work meant the rejection of interpersonal relationships, reflecting a reductionist and objectifying vision of Man.
The ‘Universalistic’ Reform
In the twentieth century the paradigm of modern science was gradually being questioned by the three ‘narcissistic wounds’ inflicted on Man according to Freud25—the discovery of non Euclidean geometries, the discovery of the subconscious and the paradoxes that threaten the foundations of mathematics and logic. Besides the awareness of the crisis of modern science, the acknowledging of the vulnerability of what can be called the risk society favoured the progressive affirming of a more complex view of the relation between Man and Nature, not in terms of control and dominion, but of harmony and interdependence. At the same time, human beings started to be considered as strictly connected to their relational networks, and a more integrated vision of the individual as the product of multiple linked factors became the norm. An epistemological approach emerged, which linked the object to its context, therefore recognising its singularity, locality, temporality, and all not falling within the pattern of reduction and de-contextualization.
This cultural revolution evolved jointly with other developments in the epidemiological and epistemological fields. In the midst of the decline of acute infectious illnesses, new pathologies emerged, generated by complex and combined causes, partly unknown and characterized by no clear pharmaceutical remedy. In addition, following the indiscriminate use of antibiotics, pathogenic processes became chronic, transforming the fight between medicines and bacteria from a sporadic battle to a protracted war with neither winners nor losers. The epistemology of medicine gradually underwent the transition from a criterion of strong causality, typical of infectious diseases, to that of weak causality, typical of chronic-degenerative illnesses.26
All these developments formed the backdrop to a series of demands that were being made in the 1960s and 1970s by the ‘Movements for Health’, inspired by the new ideas emerging in many industrialised countries: the concept of the universalism of medical assistance, developed in the throes of the ‘liberation from need’ philosophy, sustained by the Atlantic Charter (1941); that of ‘welfare from the cradle to the grave’, as endorsed by the Beveridge Plan,27 and of health considered as ‘a state of total well-being—physical/psychological/social—and not merely absence of illness’, as defined in the 1948 WHO (World Health Organisation) constitution.28
In this context, after a tortuous and time-consuming political process, a massive restructuring was carried out in 1978 under the law 833, which instituted the National Health Service (Servizio Sanitario Nazionale) with universal, publicly-funded access to healthcare. Universal coverage entitled all citizens, regardless of their social status, to equal access to essential health care services. These services—provided free of charge, or at a minimal charge—included general medical and paediatric services, essential drugs and those for chronic diseases, treatments administered during hospitalization; rehabilitation and long-term post-acute impatient care; instrument and laboratory diagnostics, as well as other specialized services for early diagnosis and prevention. The reform maintained the bureaucratic-hierarchical model of the mutualistic system, while renewed the medical-health agenda by acknowledging the new conceptions of health, illness and medicine.29
As highlighted in our previous study,30 the emerging demands of the post-modern cultural debate—the recovery of the ecological connection Man/Nature, and a holistic vision of Man—are reflected in two of the main objectives of the Reform: the shift from ‘cure’ to ‘care’ (and the consequent reduction of hospitalization and reinforcement of community services) and the acknowledgement of subjective elements (by means of continuity of care and integration between hospital and community services).31
In the perspective of passing from ‘cure’ to ‘care’, the management or governance of Health Services was devolved to Local Health Units (LHUs),32 which were called upon to integrate health education, prevention and specialist hospital and community care. The new organisms were considered agencies of the Local Governments, therefore they had no institutional autonomy and were governed by Management Committees made up of political appointees.33 Their structure was based on the principle of normative standardization and hierarchical organization of activities. The same applied to hospitals, which were absorbed by the LHUs, and depended on the Health Coordinator, for health matters, and on the Administrative Coordinator, as regards administrative matters.
Different and innovative approaches emerged on the medical scene, showing different conceptions of health/illness and diverse points of view as regards the organization of health services: one approach was ‘preventive medicine’, defended by epidemiologists and hygiene specialists, which characterized the services of Departments of Preventive medicine; another innovative area was what could be called ‘community medicine’, including a range of extra-hospital services such as palliative care, long-term care, home-care, hospices, rehabilitation. These services had in common patient-centred methodologies and long-term multidisciplinary (therapeutic and rehabilitative) programs, which the various medical and para-medical professionals developed independently over time.
As regard the continuity of care, the ‘Districts’, as basic units of health assistance, had to guarantee the integration of health interventions at a specified territorial level, and the ‘Departments’ had to guarantee the integration between wards and services inside the hospitals.
In practice, if the results of the 1978 Reform are to be analysed in terms of structural and process changes, it appears that its innovative nature did not coincide with its success. The progress of ‘preventive medicine’ and ‘community medicine’ appeared to be slow and halting, not only because of the extreme complexities intrinsic to the field, but also because of unremitting pressures, from within as well as from outside, to conform to scientific methodologies, basically mechanistic and reductionist. Prevention was interpreted in a reductionist and formalist way.34 Of the more than twenty characteristics of modern preventive medicine given by Garrison,35 bacteriological aspects were mostly developed in Italy, and prevention was mainly reduced to vaccinations and the simple prophylaxis of infectious diseases. An exception was made for early diagnoses, which indeed stimulated health consumerism. The staff of the Preventive Medicine Departments was trained to inspect and control rather than to promote good health. Hospitals continued to be the pivot on which the entire system hinged: the number of hospital beds per inhabitant in Italy was still significantly higher than the EU average. De-hospitalizing was achieved, but in the sense of the spreading of day hospitals rather than home care. The network of local surgeries, rehabilitation therapy and residential/home care was poorly developed and extremely bureaucratic. In addition, GPs, just like in the mutualistic system, were seen primarily as bureaucrats, their role mainly being to hospitalise patients and prescribe medicines and clinical tests, rather than to educate people and promote health. Since an adequate health culture had not yet been developed, citizens realized that the Health Service existed only when they were ill and it was at that precise moment that they demanded to be sent to hospital.36
As regards the continuity of care, medical information dealing with each patient did not circulate within the system between the Health Services involved, but was taken by hand personally by the patient, who was a sort of errand boy who sews together the various parts of the system.37 More bureaucracy was one side effect of preserving the administrative model in the healthcare system. In practice this meant that every activity concerned with the external environment was ‘deliberated’ by the Management Committees, which were consequently involved in managing administrative activities rather than in defining healthcare policies as was intended. Rules were complied through slow, inconclusive, formal procedures, whilst outcomes were mainly achieved through informal arrangements.
In addition, although in the new structural model of the NHS there was an acute need for vertical integration (prevention, diagnosis, therapy and rehabilitation) and horizontal integration (different services), calling for very strong management skills, no management training scheme was put in place.38 Besides, it should be noted that the Reform Act was imposed top–down when the ‘movements for health’ had already long dwindled; consequently, the institution of a universalistic NHS coincided with the crisis of European Welfare Systems. In addition, the legal dispositions had no cultural influence on the key players in the health arena: the legislation was enacted without the patients’ involvement (without promoting Health Education and Self-Health) neither were the ‘doctors/carers’ involved or a re-systemizing of medical studies suggested. The training model of medical Faculties, the regulations of which depended on the Public Education Minister, and not on the Health Minister (the endorsee of the 1978 Reform), remained informed to the instructional paradigms of positivist medicine, and was not aimed at providing full education in terms of the human being.39 Professional culture remained anchored to a sectorial perspective which, at the medical level, was translated in the myth of specialization, while, at the organizational level, continued to conceive of a system of services divided into compartments, and therefore, it matched the bureaucratic paradigm, re-proposed in its integrity by the 1978 Reform.40
The ‘Managerial’ Reform
After 10 years from the Law no.833, it appears that the expected results had not been achieved and the Italian Court of Auditors was often obliged to intervene. According to an international comparison among 10 countries, Italy, together with the United States, had the lowest level of citizens’ satisfaction with their health care system.41 Likewise, according to a 1992 European survey, Italy had the highest level of public discontent as regards quality and efficiency of health services.42 Citizens were claiming better conditions in hospitals and better health services through the Courts for the Rights of Patients: the instrument for their emancipation was the legal struggle and the language was that of fighting against the holders of power, regarded as counterpart.43
The substantial failure of the 1978 healthcare reform was regarded as the result of not having renewed its administrative model and, at the beginning of the 1990s, the time seemed ripe for an administrative modernization of the Italian NHS in relation to a series of concomitant factors: the hegemony of Reaganian/Thatcherian-inspired policies; the extension of a managerial approach (New Public Management) to the public sector and the connected reformist trend inaugurated by the United Kingdom; the loss of legitimacy on the part of national and local governments as a result of cronyism and the politically influenced degeneration of LHUs; financial and budgetary restrictions; the significant raising of citizens’ expectations combined with little trust in public institutions, a constant on the part of Italian citizens.
In the face of these developments, in 1992 another Reform came into force which modernized the LHUs on a managerial scale, while preserving the inspired principles of the 1978 Reform on the medical-health scale. The professional figure of a Managing Director was introduced, appointed by the Regional government and supported by a Health Manager and an Administrative Manager. These senior executives were chosen from those on a national list and, in order to be eligible, had to be graduates and to have worked for at least 5 years with a good record of achievements, either in private companies or in state-controlled companies or public administrations. Their renewable, 5-year privately stipulated contracts attributed managerial autonomy and demanded accountability for economic results, envisaging a dismissal clause. Concomitantly, a separation between providers of Health Services (Hospital Trusts) and purchasers (LHUs) was introduced, together with funding schemes which, under the varied forms adopted in the diverse regions, were designed to stimulate a virtuous circle based on competition among providers of health services. These schemes financed the providers no longer in relation to expenditure but rather in relation to output (weighted by Diagnostic Related Groups—DRGs), while funded the purchasers (LHUs) in relation to a (more or less ‘adjusted’) capitation quota. The main emphasis was on economic results, and therefore several managerial tools—such as budgeting, standard-setting, performance-related pay, managerial accounting—were introduced by law into LHU and hospital trusts.44
The innovations were reinforced by subsequent managerial reforms of the entire public sector, such as the reform of the civil service, considered by many commentators as a history-making event, which introduced Citizen Charters,45 Offices for Relations with the Public and performance evaluation for managers (Legislative Decree 29/1993); the reform of the Court of Auditors, which shifted the focus of controls from ex-ante ‘authorization’ to ex-post ‘effectiveness’ (Legislative Decree 24/94); the administrative simplification, which aimed at reducing the administrative burdens on citizens (Legislative Decree 127/97); the decentralization reform, which delegated responsibilities to the Regional Authorities and Local Governments (Legislative Decree 112/98); the introduction in the public sector of modern managerial tools, such as budgeting and accrual accounting (Legislative Decrees 279/97 and 286/99); the establishing of a form of ‘spoil system’ for top management positions, which were made temporary and subject to performance appraisal, while the appointment of managers from outside the public sector was facilitated (Legislative Decree 80/98).46
In practice, if the results at the level of implementation of authoritative decisions in the specific areas are evaluated, there is general consensus in the Italian and international literature that these reforms were scarcely effective, being informed by the very logic—bureaucratic—they were called upon to change.47
Also in the healthcare sector the real opportunity for innovating in a managerial sense had been wasted. The new tools of management settled by law were seen as bureaucratic requirements, which, instead of facilitating management, introduced rigidity in the functioning of the organizations.48 In addition, legislation established clearly the separation between politics and administration, but, since the power to appoint, assess and remove top managers was reserved to regional politicians, this often provoked the opposite effect, reinforcing political control on bureaucracy.49
The so called ‘administrated competition’ did not really work, due to the lack of accurate information regarding costs and services and the inadequacy of the skills available. Nevertheless, the new funding mechanisms pushed for a sort of ‘pan-economicism’, thus inducing ‘Health Service consumerism’50 and ‘hyper-medication’, while penalising investments in prevention and in any activity that had not immediate positive effects on the financial balance sheet.51 Besides, the purchaser/provider split favoured a focus on the internal functioning of the organisation to the detriment of the trend towards inter-organisational cooperation and integrated services, thus hindering the continuity and integration of health care.52 A self-referential approach was the result, which led providers to consider as their chief mission the maximization of the services offered, rather than the satisfaction of their target population’s health needs. In particular, Regions in the North of Italy drew on their efficient and advanced health organizations to attract patients from the South, thus increasing their own revenues and funding further investments. This accentuated inter-Regional patient mobility as well as disparities between the North and South of Italy, as emerges from an analysis of health indicators, the most significant of which is the infant mortality rate.
The ‘Clinical Governance’ Reform
On the whole, the innovations introduced in 1992 were phagocytized by approaches we could define as ‘managerial positivism’, found to be totally obsolete in studies on the private sector business. This kind of ‘positivistic management’ (badly conceived and even worse put into practice), rather than management itself, nourished anti-business sentiments. Besides, a new cultural shift was taking place in Italy, related to the Clinton-Blair reforms in favor of the Welfare State and to the spread of new ideologies on how the public sector should be organized, namely the emerging paradigm of the New Public Governance which were replacing the traditional New Public Management.
In this context, another top–down health Reform was introduced in 1999, which launched the ‘clinical governance’ model as an attempt to respond to ‘pan-economicism’ and the related erosion of professional autonomy. The model entailed the involvement of clinicians in a widespread managerial framework, underpinned by a chain of responsibility that linked the upgrading in terms of pay and position to the achievement of defined objectives, and, conversely, its downgrading to failure to achieve such objectives. Furthermore, the 1999 Reform Act stipulated the adoption of guidelines and diagnostic-therapeutic paths, based on the principles of Evidence-Based Medicine (EBM), in order to favour the development of systematic methods for the monitoring and evaluation of clinical practice. To this purpose a ‘National programme of guide-lines’ was put in place, to produce useful information, improve access to information and monitor the adoption of guide-lines and their impact. The law also sanctioned the principle of ‘exclusiveness’ for physicians working in the National Health Service, thus reducing physicians’ margins of discretion stemming from their dual role as public sector employees and free lance professionals. In addition, taking into account the shortcomings in university education, legislation introduced the ‘Permanent Medical Education’ (‘Educazione Continua in Medicina’—ECM) programme, stipulating mandatory in-service training as a pre-requisite for promotion and better remuneration for all healthcare workers (not only physicians).53
A further decision was to improve the integration of Health Services, by: (1) reducing the divide between purchasers and providers, by imposing more stringent requisites (compared with 1992 Law) on hospitals to opt out from the Local Health Units and to become independent Trusts, (2) strengthening intermediate units—Districts54 and Departments55—by endowing them with financial and technical autonomy.
In order to keep to a minimum differentiation and territorial non-uniformity, centralization was re-proposed through the use of structures accreditation, the control—both direct and indirect—of the purchasing functions, and the imposing of cash limits and services ceilings.56
Despite its far-reaching approach, even the 1999 reform displayed a marked implementation gap, falling back upon ‘traditional’ models.
The emphasis on the assessment and the control of clinicians led to ‘clinical economics’ that were much more worrying than ‘business economics’. The reductionist approach of EBM, finalized towards governing, guiding and controlling professionals by rendering explicit what could be considered tacit knowledge, engendered mistrust in the players involved and provoked defensive attitudes. Similar effects were generated by the ‘principle of exclusiveness’ for physicians in the Public Health Service Sector. The permanent medical education programme did not contribute to involve doctors, offering update or refresher courses rather than ‘acculturation’.
The integration of hospitals and communities, as well as the continuity of healthcare, remained illusory. Regarding the Districts, in practice there was little coordination of the activities in the different services and such integration as did exist was most often based on personal contacts; as concerns the Departments, there was scarce collaboration among the various wards, which were still considered ‘hospitals’ within a hospital, provoking considerable problems both of communication among physicians and of integration with primary care. On the whole, the task of fitting health assistance into a single and coordinated process was still the responsibility of the user, who was obliged to pass from one service to another to acquire specific elements of the process, without links being put in place by the Health Service. Bureaucracy permeated even the medical profession itself: bureaucratic dispositions defined duties as though they were of an executive director who has bureaucratic autonomy and, at the same time, bureaucratic responsibility. Consequently, clinical governance ended up being a sort of ‘clinical neo-bureaucracy’.57
The reinforcement of centralized planning, aimed at reducing inequality in the territory, turned out to be ‘administrative neo-centralism’58 which, through sectorial cash limits and services ceilings, limited the autonomous initiatives of LHUs and hospitals, thus toppling the model of administrated competition evoked in the rhetoric of the 1992 Reform. In addition, it appears that the magnitude of the inequalities was still significantly high and the mobility of patients across regional boundaries was still considerable, particularly from the less efficient hospitals of the Southern regions to the more advanced of the Northern regions.
Also in the case of the 1999 Reform, the lack of a strong cultural policy is to be noted. Medical faculties continued to promote a professional culture anchored in extreme reductionism (as demonstrated by the flourishing of specializations and sub-specializations) and focussed on hospital rather than on community medicine. Moreover, among top managers not characterized by a clinical background, legal competences continued to prevail over managerial expertise.59
Some years ago the magazine Premiere reported the results of an enquiry on how the famed endings of Hollywood movies had been translated into various languages. The end of “Go with the wind” with the renowned “My dear, I couldn’t care less” of Clark Gale to Vivien Leigh, had been translated into Japanese “My dear, I am afraid there is a little misunderstanding between us”, in homage to proverbial Japanese courtesy.
With reference to the modernization of health care, despite Italy has emulated the reformist trends of post-industrial countries with continuous and massive restructuring of health care (the impressive level of intervention being determined by the perceived scale of the problems), a peculiar process of translation has taken place, by means of which the ground-breaking content of the reforms has been mitigated by a technocratic juridical framework, regressing to a traditional positivism which is quite distant from the paradigm of New Public Governance emerged in the other post-industrial countries. This is summarized below.
On the medical-health scale, the pillars on which the 1978 and 1999 Reforms were based—prevention, de-hospitalization, community medicine, integrated care—albeit in line (as we conclude in our study on the evolution of medical and healthcare models)60—with the demands of a post-industrial society, remained a magic formula with low impact on the real dynamics of health care. Despite the rhetoric of continuity of care, the LHUs proved to be hardly capable of promoting integrated health pathways within a finicky and disconnected system, centred on institutions—the hospitals—which founded their power on discontinuity, discontinuity between the time and place of the health care and that of the patients’ daily life, between the scientific and the not-scientific, the rational and the irrational. Even when integrative organisational schemes—such as Districts and Departments—were adopted, their underlying philosophy continued to be fragmented. Obviously, since a reform of medical and business studies had not been carried out, and therefore the conceptual apparatus of medicine and management had not been updated, the ontological and scientific statutes of the organizations remained unchanged (starting from the basic units, respectively, the physician–patient and the manager–subordinate relationship); consequently, there were not the conditions for integration on a conceptual level, propaedeutic to more radical and complex organizational interventions.61
While clinical governance has been theorized as a mechanism for the involvement of physicians, in Italy it has been interpreted as a mechanism of surveillance and control, thus stimulating formalistic and defensive behaviour, risk aversion and closure to innovation on the part of professionals.
While the empowerment of patients has been emphasized as the response to the changing needs and attitudes of the end-users of health services,62 in Italy it has been interpreted on the basis of the positivistic-juridical framework (significantly, patients’ associations were called Courts for Rights of Patients) emphasizing the idea of lack of relationships and conflict between two counterparts.
At the same time, while the management of health care has been theorized as a ‘soft’ type of administration inspired by the concept of governance, founded on the mediation between different rationales and on a process of co-production with the different subjects involved, in Italy, interestingly, it has taken the form of ‘hyper-government’, i.e. a self-referential centralist and mono-rational administration governed by a strong monocratic body, appointed by a political subject. This has resulted in the need for a top down approach to command (whereby the top manager imposes his own order on the organization) and control (by which he verifies that such order is pursued and maintained), the outcome being defensive tactics and lack of mutual trust.
While the New Public Governance paradigm, in the light of the changed cultural, epidemiological, socio-economic scenarios, advocated the introduction of innovative models of management by processes and the development of forms of inter-organizational cooperation, in Italy, despite the rhetoric of ‘governance’, managerial reform has favoured a sharp focus on the internal functioning of the organization, to the detriment of the trend towards inter-organizational integration, thus failing in the objective of continuity and integration of care. Furthermore, the exclusive focus on efficiency has resulted in the shifting of economies from one sector to another, and in particular savings in hospitals shifted the cost of care onto other providers of health care.
Besides, while the NPG—in the light of the increasing complexity and turbulence of the health care arena—advocated a conceptualization of the Health Service Sector as a dynamic and evolving system put in place by a plurality of (internal and external) actors, following transformational self correcting processes, in Italy the 1992 and 1999 reforms underpinned a rational-comprehensive model, centred on planning and budgeting approaches. This merely produced an abstract exercise or official practice which, instead of facilitating management, introduced further elements of rigidity, and merely shifted attention onto the quantitative aspects of health services.
While the NPG model rejected the Weberian concept of ‘neutral’ administration in favour of an ‘instrumental’ conception, according to which management in the public sector has to contribute to the process of defining strategic objectives, on a par with politicians, according to an interactive relationship, in Italy, the scientificity and neutrality of managerial methods has registered remarkable appeal, being considered a moral antidote to the degeneration of politics, but in practice, the appointment of professional managers in place of political party nominees did not reduce the level of politicization, since the possibility for Regional governments to substitute Managing Directors and relate their pay to performance resulted in reinforcing the political subordination of the managers involved.
On the whole, it seems that the various reforms have lost their innovativeness, and have been absorbed within the traditional positivist approach (specifically, the administrative-managerial paradigm and the biomedical model). This has led to their incompleteness and inadequacy, pushing the entire system towards a chasm between theoretical and practical effectiveness.
There are however excellent examples of effective attempts to overcome the biomedical model, such as some applications of ‘psycho-somatic’63 medicine, which bridges the gap between the two parallel, but independent ideologies of medicine—the ‘biomedical’ and the so called ‘bio-psycho-social’,64 or some applications of ‘green medicine’,65 which focus on the sustainability of medical practices and the reduction of medical waste, but these remain sporadic initiatives which are lost in the numerous rivulets making up the medical field, and denote the pragmatism of a variegated and negotiated order of professionals, rather than genuine evidence of theoretical integration as a new shared anthropo-ecological orthodoxy providing a permanent resolution to the limitations of the biomedical model.
On the managerial ground, there are also successful applications of the new logic of governance to the domain of bureaucracy in some specific units or organizations, but they remain ‘patchy’,66 and the process of managerialization appears to be broken up into smithereens which coexist as unfinished pieces of a monument to Scientific Management.
So, the question is, why has the positivist approach been so predominant to the extent that its resistance to change has created significant problems of translation? There is some general consensus in Italian and international scholarly debate about the overarching influence of two powerful paradigms—the ‘biomedical’ and the ‘administrative-managerial’—that strongly conditioned the functioning of the Italian Health Care system.67 These, by reinforcing one another, yielded infertile ground for its renewal in a post-modern sense.
The two models, being strongly entrenched in the Italian culture and conceived on a sub-conscious level, had insidious effects on the broad concepts of ‘medicine’ and ‘management’. Both the ‘biomedical paradigm’, which led to significant advancements in treatment, dominating medicine for about 300 years, and the ‘administrative paradigm’, a spectacular success of the Prussian State, later turning into the ‘scientific management paradigm’ and becoming one of the key drivers of economic growth in the twentieth century, came to be associated with the broad concepts of ‘medicine’ and ‘management’. For most people, the word ‘medicine’ conjures up images of impersonal-reductionist treatment, for reasons that have nothing to do with the underlying meaning of the term; similarly, the concept of ‘management’ is evocative of the idea of hierarchical control, just because the two concepts (‘management’—‘hierarchy’) became intertwined in the 1920s, thus preventing any alternative formulation. So, the ‘biomedical model’ and the ‘scientific management’ have become the cultural specific perspectives, namely the ‘folk models’ for medicine and management, because they are part of the fabric of education which is taken for granted, the cultural background against which people learn to become physicians or managers. The teachers, the texts, the notions that are taught, the practices that are shown, all reflect the predominant paradigms, which are never made explicit. An explicit outline is indeed traced in the following paragraphs.68
The Administrative Paradigm
The ‘administrative paradigm’ denotes the centrality of a specialised branch of law—so called ‘administrative law’69—in the overall administrative activity of public organizations.70 This entails the cultural predominance, amongst civil servants, of experts of ‘administrative law’ over management experts and, based on a merely juridical conception of the public administration, a legalistic approach to reforms: these are considered practicable only by means of laws and regulations, which can only be reversed by going through articulated and costly procedures, and the implementation of which can be carried out by adapting, at different levels of government, the secondary body of laws regulating each sector.
The legalistic approach to reform seems to have had an effect in the sense of reinterpreting, according to juridical frameworks, the content of management reforms, thus resulting in the total hollowing out of the managerial substance, or in its being set within a positivist cognitive framework (namely, the Scientific Management à la Taylor).
This can be found in all the areas of the Italian Public Administration: apart from some sporadic situations, in every part of the public sector—from central ministries to public utilities,71 from the university to the justice system,72 from local governments to railways73—and in every functional area—from human resource management to marketing,74 from procurement to information systems,75 from strategy to organization,76 from accounting and control to finance77—the process of managerialization has taken a top–down, juridical approach, informed by the very logic and ethos it was called upon to change.
The administrative paradigm, closely related to Italy’s distinctive culture and history (mainly, the centralist-authoritarian origin of the Italian Public Administration78) has shown an extraordinary endurance, deriving from its capacity of self-reproducing, absorbing within its doctrinal constructs any principles, even the most innovative, purging it of its most significant elements,79 thus matching that obscure tendency of Italian public administrations to transform the objects of their interest into something bureaucratic, therefore controllable and structurable according to juridical schemes.80
Recently there has been a growing interest in New Public Governance and in other post-modern approaches, such as Critical Management Studies or other non traditional approaches such as the pioneering or more recent works by Mintzberg,81 but this resulted in rhetoric exercises more than in substantial changes, as shown by Adinolfi .
The Biomedical Paradigm
The positivistic tradition is further reinforced in the Italian health care system by the biomedical paradigm and the professional dominance of its adherents.
Such a paradigm considers disease as a deviation from the norm of measurable biological variables, a disordered process intervening in a naturally ordered world, that Man can understand, and therefore fully control, by means of the medical tekne. Within this positivistic framework there is no room for the socio-psychological, spiritual dimensions of illness. In the biomedical model not only disease is treated as an entity independent from social behaviour, but even behavioural anomalies are treated as disordered somatic (biochemical or neurophysiological) processes. Embracing the reductionistic view that complex phenomena are ultimately derived from a single primary principle,82 the biomedical model is based on the physicalist principle, implying that biological phenomena can only be explained by the language of physics and chemistry. Biomedicine also embraces a rational, analytical approach by means of which entities to be investigated can be classified in separable causal chains or units.
In this conceptual framework, it is clear why doctors seem to conform better to the demands of positivistic management rather than to that of post-modern society, and why there are significant synergies between the administrative and the biomedical paradigms, at least in some respects and with the obvious caveats that apply to attempts at generalising on such a scale as is the case when ‘paradigms’ or ‘models’ are being discussed.
Like the juridical community, also the biomedical community has proved a considerable capacity for survival. As Holman observes, professional dominance “has perpetuated prevailing practices, deflected criticism, and insulated the profession from alternate views and social relations that would illuminate and improve health care”.83 To this, the power of vested social, economic and political interests can be added. The huge investments in diagnostic and therapeutic technology alone strongly favour impersonal and mechanistic approaches to clinical study and to patient care.84
Recently there has been growing disenchantment towards a mechanistic and impersonal approach to patients and an upsurge of interest on the part of various physicians in primary care and community medicine. Even from some academic circles there is a revival of interest in a more holistic approach, and also from Physicians’ Councils sharp criticism is starting to address the dogmatism of biomedicine. Emblematic is the 2009 conference—“Thinking for the medical profession”85—as well as the 2012 conference—“Philosophy for medicine”.86 However these initiatives are still few in number and lack the influence, power and access to funding from peer review groups.
Our analysis confirms the relevance of philosophical barriers—namely an entrenched positivist approach—to a health promotion agenda. The three health reforms carried out in Italy to realign medicine, health and society, all failed to overcome these barriers. The reasons are related to the fact that the Reforms were not conceived to break the positivistic monopoly of the two hegemonic paradigms (the administrative-managerial and the biomedical): they did not comply with social and political movements in support of health, privileging rather top–down legislative changes and did not involve the main actors (physicians and administrators), nor did promote cultural or educational intervention. In other words, the organization of the system has been reformed without changing the mould that drives the behaviour of the main protagonists of the reforms—doctors and administrators.
This could explain the increasing distance between the theoretical efficiency and the practical effectiveness of the Italian NHS and its current crisis of detachment from the social system. The condition of crisis might indeed offer an important occasion for learning. Einstein  stated that, in order to overcome a crisis, one should avoid being inspired by the same ideological components that triggered it. Consequently, positivistic influences should be eliminated.
In this context, to allow for a realignment between health, medicine and society, interventions that act at a cultural level, building on compatible economic, social and cultural forces, seem to be most promising. This implies that health policy-makers (at both national and regional level) cooperate with their counterparts from other government sectors to develop public policies that go beyond the limits of health sector control.
An important sector is university education for doctors and managers: a reform of medical and business faculties as well as of ECM programs should shift the focus from instruction to acculturation, training professionals who are not only specialised in their field but also cultivated. Rather than offer students narrow sets of tools and techniques, failing to provide the breadth of perspective or the ethical grounding, they should arm them with a far less narrow-minded outlook on the ideas they teach—the theoretical assumptions on which they are based, the era in which they were created, and the difference between underlying principles and visible practice.87
Furthermore, decisive changes should also be made concerning training methodology. Both medical and managerial education should not be teacher-centred but rather learner-centred; it should not teach medical specialties/business functions but rather enhance the practice of curing/managing; it should not rely on learning from other people’s experience, but rather help physicians/managers make meaning of their experience, by reflecting on it personally and with their colleagues.88
If several years of university education are required to produce a physician or a manager, thanks to immigration it is possible to acquire immediately the human capital needed to promote cultural change. Consequently, immigration policies should be devised to attract adequately acculturated people to the Italian National Health Service. An example of paving the way towards putting this in place could be that of reducing the weighty bureaucratic burdens on them.
Educating general public could also be useful, offering alternative messages to the dominant biomedical and lifestyle discourse. Engaging and nurturing key individuals may indeed be more effective in bringing about system-wide change as opposed to merely targeting the behaviour of every individual. All these possible measures should be analyzed and evaluated.
Such index selects a limited number of indicators, within a definite number of evaluation areas (patient rights and information, e-health, waiting times, outcomes, range and reach of services provided, pharmaceuticals), ‘which in combination can present a telling tale of how the healthcare consumer is being served by the respective systems’ [19, p. 11], in other words it evaluates the ‘consumer friendliness’ of health care systems (ibidem, p. 16). It appears that the top countries are those, like The Netherlands, where healthcare operative decisions are mainly taken by medical professionals with patient co-participation, while financing agencies and healthcare amateurs such as politicians and bureaucrats are removed from operative healthcare decisions.
The infant mortality rate measures the number of children dying under a year of age dived by the number of live births that year. According to the data from the Italian National Institute of Statistics (ISTAT), the main producer of official statistics in the service of citizens and policy-makers (http://www.Istat.it), while the Italian average is 3.8 per 1,000 live births in the year 2005, Southern regions present significantly higher values (Calabria: 5.43, Sicily: 5.05, Basilicata: 4.70; Puglia: 4.55; Campania: 4.29).
Ongaro provides some explanations for this: the relative closeness of academic community of public administration and public management, which may be relatively less globalized than others; the presence of linguistic barriers in countries where English is spoken to a lesser extent; the lower interest elicited by these countries as analytical cases in that have undergone minor changes .
According to the 1978 law, LHUs comprise “the set of units, offices and services of the local authority councils, which in a certain area perform the duties of the NHS”.
The members of the management committees were appointed by the general assembly of the LHU, composed of councillors of the local governments included in the LHU territory. They were generally low profile political activists with very little previous administrative experience .
Most of directors within the Italian healthcare system had legal rather than managerial competences.
Citizens’ charts were contracts with the citizens in which public administrations were publicly committed to delivering services at predefined levels of performance.
The District was the functional division of the LHU which coordinated care delivered by general practitioners (GPs), GP paediatricians, counselling centres for family planning, nursing home care and local social services; the District also integrated primary care, specialist care, health promotion and epidemiological surveillance. In practice, Districts had to facilitate horizontal integration of all primary care services.
Departments had to integrate the activities of interdependent wards and services. The coordinator of the Department had to be appointed from among the consultants of the wards and services involved in the Department.
Unlike in Anglo-Saxon countries, in Italy relations between the public administration and citizens are regulated by a special law—‘diritto amministrativo’—which conceives of citizens as totally submitted to a discretionary Administration. It is significant that in Anglo-Saxon countries the word ‘service’ is used to qualify the activity public agencies carry out for the citizens (‘civil service’, ‘public servants’), while in Italy the only term is ‘administration’.
Unlike in other European countries, in Italy the centralist-authoritarian logic prevailed over autonomist instances and the unification of the country was driven by the Savoyard dynasty, whose military-hierarchical tradition had a Napoleonic heritage .
Una filosofia per la medicina, Conference organized by Centro Oncologico Fiorentino, Sesto Fiorentino, January 2012.