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Barriers to Reforming Healthcare: The Italian Case

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Abstract

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.

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Notes

  1. World Health Organization [61].

  2. Björnberg et al. [19].

  3. 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.

  4. Cavicchi [26, passim].

  5. CENSIS [29].

  6. 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).

  7. Adinolfi [5].

  8. Raphael et al. [56].

  9. Ongaro [52, p. 1].

  10. 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 [52].

  11. Adinolfi [8].

  12. Adinolfi [9, 11] and Adinolfi and Mercurio [13].

  13. Adinolfi [7, 10] Adinolfi and Mele [12].

  14. Ongaro [52, pp. 21–22].

  15. Pollitt and Bouckaert [55].

  16. Caiden [23].

  17. Pollitt and Bouckaert [55].

  18. Ongaro [52, ibidem].

  19. Adinolfi [5].

  20. Ongaro [52, ibidem].

  21. Cosmacini [31, p. 69].

  22. Marsicano and Delle Fave [45].

  23. Cosmacini [31], ibidem].

  24. Cosmacini [32, pp. 114–116].

  25. Freud [38].

  26. Gadamer [39].

  27. Beveridge [17].

  28. Cosmacini [30, p. 116].

  29. Cosmacini [32, ibidem].

  30. Adinolfi [5].

  31. Adinolfi [7].

  32. 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”.

  33. 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 [40].

  34. Cosmacini [30, p. 116].

  35. Garrison [41].

  36. Cosmacini [30].

  37. Freddi [37].

  38. Most of directors within the Italian healthcare system had legal rather than managerial competences.

  39. Cavicchi [26, p. 255].

  40. Adinolfi and Mele [12].

  41. Blendon et al. [20].

  42. Rico and Cetani [58].

  43. Spinsanti [59, p. 129].

  44. Adinolfi [7].

  45. Citizens’ charts were contracts with the citizens in which public administrations were publicly committed to delivering services at predefined levels of performance.

  46. Ongaro [52, pp. 72–75].

  47. Ongaro [52, ibidem].

  48. Adinolfi [10].

  49. Longobardi [44, p. 182].

  50. Illich [43].

  51. Alfieri [15].

  52. Cavicchi [27].

  53. Adinolfi and Mercurio [13, pp. 67–80].

  54. 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.

  55. 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.

  56. Adinolfi [10, ibidem].

  57. Cavicchi [26, passim].

  58. Cassese [25].

  59. Borgonovi [22].

  60. Adinolfi [5].

  61. Cavicchi [28, passim].

  62. Tengland [60].

  63. Grandi et al. [42].

  64. Engel [34].

  65. Palazzo [53].

  66. Ongaro [52, passim].

  67. Ongaro [52, passim].

  68. Birkinshaw [18, p. 111].

  69. 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’.

  70. Ongaro [52, ibidem, p. 11].

  71. AA. VV [4], Mercurio and Martinez [48].

  72. Adinolfi [6], Adinolfi and Piscopo [14].

  73. AA. VV [1], Adinolfi [8].

  74. Rebora [57] and Festa [35].

  75. AA. VV [2, 3].

  76. Mele and Storlazzi [47] and Borgonovi [21].

  77. Panozzo [54] and Borgonovi [22].

  78. 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 [46].

  79. Capano [24].

  80. Rebora [57, p. 302].

  81. Mintzberg [49, 51].

  82. Engel [34].

  83. Holman, H. R., cited in Engel [34].

  84. Engel [34].

  85. Benato [16, p. 129].

  86. Una filosofia per la medicina, Conference organized by Centro Oncologico Fiorentino, Sesto Fiorentino, January 2012.

  87. Birkinshaw [18, p. 263].

  88. Mintzberg [50].

Abbreviations

EBM:

Evidence Based Medicine

ECM:

Educazione Continua in Medicina

DRG:

Diagnosis Related Groups

ISTAT:

Italian National Institute for Statistics

GP:

General Practitioners

LHU:

Local Health Unit

NHS:

National Health Service

NPG:

New Public Governance

NPM:

New Public Management

WHO:

World Health Organization

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  1. Università degli Studi di Salerno, Via Ponte don Melillo, 84084, Fisciano, SA, Italy

    Paola Adinolfi

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Adinolfi, P. Barriers to Reforming Healthcare: The Italian Case. Health Care Anal 22, 36–58 (2014). https://doi.org/10.1007/s10728-012-0209-0

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