THE RIGHT TO HEALTH IN ITALY

 

by Paola Poli

Secretary of the Citizens’ Movement

 

1978 – 2004

 

The great and genuine health reform carried out in Italy, on December 23rd 1978 is governed by Law 833 that institutes the National Health Service. In the same year, and together with the aforementioned law, the law on mental health was passed, which is also very important regarding ethical as well as social principles and values.

                 

INFORMING PRINCIPLES AND OBJECTIVES OF LAW 833/78

 

In reference to Section 32 of the Constitution that protects the right to health as a fundamental human right for the individual and the interest of the collective, the Law 833 instituting the National Health Service is defined as a set of functions, services and activities intended to promote, maintain and restore the physical and mental health of the whole society, with no distinction whatsoever.

          

The principles:

 

the set of interventions related to prevention, treatment and rehabilitation; equality of all citizens in relation to the Service; uniformity of interventions between public and private institutions whose activities have an impact on the citizens’ health; the citizens’ participation in the Service through activities that guarantee a non-institutional control over the Service’s efficiency and efficacy at the different interventional levels.  

 

The objectives:

 

overcoming the regional unbalances in relation to the social and health condition of the country by means of an adequate health programme and a coherent distribution of the available assets; health education for all citizens and communities; prevention of illnesses and accidents in all places of residence and of work; safety at work guaranteed by the joint participation of workers and unions; diagnosis and treatment of illnesses, whatever their causes; the phenomenology and the continued rehabilitation in the case of disability and incapacity; protection of mental health; responsible procreation and protection during maternity and infancy; regulation of drug trials, drug production, trading and distribution; promotion and protection of health and hygiene in the natural living and labour environment, etc.

 

The popular referendum carried out in spring 1993 resulted in the annulment of the provisions that confer the Local Health Units (ULSS) with the responsibility for implementing environmental controls. When the Law 61/94 was later applied, the former Multilateral Prevention Organisations belonging to the ULSS were eliminated, and the Regional Environmental Prevention Agencies (ARPA, in Italian) and the National Environmental Protection Agency (ANPA, in Italian) were instituted.

 

The means:

 

The three-year National Health Plan (PSN) of the central Government establishes the general guidelines and methodology for the development of the National Health Service institutional activities, according to the availability of resources estimated within the national socio-economic schedule. Besides, the plan sets forth the objectives to be met within the three-year term; it also establishes the uniform levels of health care that must be guaranteed for all citizens; it determines the allocation of funding from the Regional Health Fund that must be entered annually in the State balance sheet and financial statements.         

According to the National Health Budget, the Regional Health Plan determines the financial trends to which the Local Health Units (ULSS) must refer; the allocation of funding that must be entered into the balance sheet and financial statements every year of the three-year term.  

 

 

 

Local Health Unit (ULSS) offices and their competence.

 

General Meeting: election of the Managing Committee, approval of the balance sheet and financial statements and of the profit and loss accounts, of the plans and schedules that demand more interventions, of the employed staff and of the rules and agreements.  

Managing Committee: appointment of the President, adoption of the Local Health Unit (USSL) administrative records, and disposition of the specific competence records of the General Meeting.

Auditing Board: signature of the balance sheet and financial statements, quarterly report on the ULSS administrative accounting management for the Region as well as for the Ministries of Public Health and Economy.

Managing Office: appointed for the organisation, coordination and functioning of all the services; it is constituted by all the responsible members of the Local Health Units (ULSS) who hold the most important positions.  

Health Coordinator and Administrative Coordinator:  chosen among the members of the Managing Office, they must ensure the coordination of the Managing Office.

 

All these organisations were eliminated when the Law 421/92 was passed, and they were substituted with other agencies as provided for in the Legislative Decrees 502/92 and 517/93.

 

 

Considerations

 

The Law 833, still in force, had virtues (currently present) as well as defects. The virtues can be recognised in the comprehensive structure of this very important law which is confirmed by the fact that other European countries have become interested in it; they can also be recognised in the capacity to provide a unified response to and an adequate planning of the health demands, and also in the universal nature of the socio-health services intended to comply with Section 32 of the Constitution.  

The defects can be seen in the government’s inability to set out conditions for health workers and mainly for politicians to act with total responsibility and with a sense of service in the collective interest, in the confused procedures, in the complex and unclear relationship between Local entities and the Local Health Units (ULSS), in the confusion of roles between political organisations directed by the ULSS (Managing Committee) and the technical organisations. 

Some mistakes are determined by the intention to provide a structural and functional response to everything, thus increasing the usual expenditure without improving services, by the lack of investment intended to acquire scientific knowledge and organisation of the ULSS in the competence area, and by the difference between profits and loss, due to the scarce autonomy of the Managing Committees, generally conditioned by the demands of political parties.    

 

In the ’80s there was a rational response to the growing demand for health protection which was summarized in the motto “everything, free and fast”: Utopia clashed with reality very soon, since the usual running costs of the National Health Service experienced a dramatic increase that tripled the balance sheet and financial statements in a few years time. This allowed the political forces against the reform to trigger an intense political offensive, inspired in the Thatcher-like model “a smaller State, a larger market” and in the totally Italian slogan “politicians, out of the health system”. Since the beginning of the ‘90s, the health sector was also marked by concepts corresponding to private market investment, competition, productivity, cost analyses, the idea of citizens considered users instead of clients, etc. 

 

1992 –1998

 

In 1992, a deep world economic crisis that in Italy came along with the outburst of Tangentopolis and the widely-known episodes involving Ministry of Health De Lorenzo. The Amato Administration, by the end of that year and under different pressures often imbued with vested interests, had to decide on an important structural and economic management, based on the approval of the delegation Law 421 dated on October 23rd 1992. Section 1 provided, among other things, for the restructuring the regulations within the health sector. Thus, in this direction, the Legislative Decree 502 of December 30th 1992 containing a thorough revision of the Law 833 called “the reform of the reform” was adopted; the law was later amended by the definite Legislative Decree 517 of December 31 1993, as a result of the offensive led by the Regions in the first place.

 

Content of the Legislative Decrees 502 and 517

 

1. National Health Plan: consolidating the importance of the National Health Plan as an irreplaceable health programme in the field of binding boundaries of the financial resources effectively available.  

 

2. Regional organisation of the system: the Region becomes the centre of the local health scenario; it is responsible for the legislative and administrative health and hospital care functions, for the regional health planning, for acting as an interface between the different levels of health care service, even in relation to setting the financial criteria.

 

3. The Local Health Enterprise: The Local Health Unit of each Commune becomes a company with a proper legal status, run by a General Manager with the help of an Administrative, a Health and a Social Board of Directors. It intends to institute an autonomous public body responsible for operating in a business-like manner and for pursuing objectives inspired with efficiency, efficacy, productivity, and quality of productive processes. It has been stated that even though the company is autonomous, the representative organisations have the inalienable right-duty to claim for the socio-health needs of the local Communes they represent.

 

4. Uniform levels of health care:  According to the National Health Plan, the Regional Health Units must ensure uniform levels of health care in their regions, compared to the volume of available assets, by means of specific health services that must be guaranteed to all citizens. The reference between uniform levels of health care and the volume of available assets is related to the need for maintaining a compatible relationship between growing demand and finances, within the framework of a plan that addresses what is possible, not what is ideal. According to some legal experts, this might imply a weakening of the absolute individual right to health (Section 32 of the Italian Constitution) and of a genuine interest.

 

5. Socio-health services: the Local Health Unit (ULSS) will directly manage the socio-health care services and activities only at the request of every interested organisation, and entirely charged to them, with the Local Health Unit’s consent, a specifically established accounting method, the subordination of the service supply and the provision of funding. It is evident that such argument intends to lead the socio-health care services towards the field of direct management by the Local entity, and to define what is social and health care in order to avoid inappropriate financial setbacks within the National Health Fund. 

 

6. Hospital structures: in order to be transformed into Trusts, the most important and highly-specialised national hospitals must have at least three high-standard specialisation structures and a departmental organisation; they must also have proper legal status, as in the case of the Local Health Units (ULSS); they must be managed by a General Director who is assisted by the administrative and health directors, similarly to what happens in the case of the Local Health Units (ULSS). A remarkable level of autonomy is guaranteed to hospitals since they are not companies and maintain the typical hospital organisation structure, with economic and financial autonomy and with accounting records entered separately into the balance sheet and financial statements of the Local Health Unit (ULSS). Hospitals transformed into trusts must have the same bodies as those provided for the ULSS, except for the regional representatives: trustee or board of trustees.

 

7. Relationships between the National Health Service and the University: overcoming the conventional model (former Section 39 of Law 833) and activating a more flexible and optional system created on the basis of specific agreement protocols entered into by the Region and the University, and on the basis of appropriate agreements subscribed by the University, the hospital Trusts and the Local Health Units (ULSS).

 

8. Health Care Services: the line of intervention is modified in order to ensure a homogeneous legal and financial treatment of the bodies registered with the National Health Service, in relation to the provisions of Law 833 that submitted to the “centralising” regulation the relationships originated within the framework of the health care services.

The registered practitioner is responsible for controlling expenses according to the planned levels of health care; group practice is preferred in order to guarantee the provision of continued daily and weekly health care service.

 

9. Complementary health care services: complementary health funds may be set out in order to provide additional health care services, apart from those guaranteed by the National Health Service through multilateral contracts and agreements, agreements entered into by independent workers and independent professionals, through non-profit organisations, mutual funds, entities, companies or local bodies. 

 

10. Quality controls: Health Companies are obliged not only to achieve efficient and efficacious results in the health and technical-economic sectors, but also to develop a management policy that satisfies customers in relation to the quality of the supplied services.

 

11. Participation: Section 14 is integrated into the context of a re-examination of the relationship between the public administration and the citizen, also under the Law 241/90, with the intention to develop restoration and promotion strategies for a health care administration capable of guaranteeing transparency, personalisation and humanisation, information, participation, counselling and control. 

 

At a regional level, indicators can be used to control the situation of the citizens’ rights, to promote citizens’ participation in opinion polls, to encourage voluntary service organisations and citizens’ rights movements, to resort to labour unions to get and give information on the organisation of the health care services, and to acquire scientific knowledge to devise useful proposals to contribute to the plan.

Establishing respect for the distinction of roles.

 

1998 – 2004

 

With the Law 419 of November 30th 1998, the Parliament delegates to the Government the responsibility to pass a Decree to improve the National Health Service, and to adopt a single text to determine the organisation and functions of the National Health Service. 

 

It is an important provision for the reorganisation of our health care system, and it is intended to clarify every single ambiguous and contradictory rule stated in the Decrees 502 and 517. It also aims at modifying the extremely economics-bound aspect of the current laws.

 

The content of the proposal defines the conditions to regard the health care expenditures as an investment, a resource used to improve all citizens’ living standards. 

 

An essential concept is stated: the protection of health is inherent to the individual’s needs, and the financial demands come in second place. This principle goes beyond balancing the balance sheet and financial statements as an independent variable that, in fact, has changed the right to health from being constitutionally guaranteed to being financially conditioned.  The provision demands that the levels of health care be set out within the context of the resources to be assigned to the health care system, and that the financial context be subject to the Economic Planning Document as well as the National Health Plan.  

 

The process of transforming into a Trust must be followed taking into account that the Health Trust produces a unique product, namely “health”, that cannot respond to the logics of benefit or the cost-effectiveness ratio which would limit the citizens’ rights; the balance sheet and financial statements cannot be the only calculation element that companies and the General Directors have; instead, it should represent the achievement of objectives to improve quality as well as efficiency and efficacy in the health care services.

 

The relationship between public and private sectors develops within the regional plan in which the real demands of the inhabitants are detected, and by means of a system of accreditation those sectors are jointly integrated.

Competence originates on the basis of the quality and efficiency of the health care services. 

 

The Regions hold total responsibility for planning and government; health federalism is introduced, and the role of the communes is strengthened within the health and socio-health planning framework, at a regional and local level, and in relation to the procedures to control the results achieved by the ULSS regarding the plans and objectives set out jointly. 

The socio-health integration can be more accurately defined by identifying the citizens’ right to an integrated health care service in some important areas such as psychiatry, substance abuse, AIDS, the disabled or impaired elderly, seriously injured or disabled individuals.  Such integration must be carried out in each district, even through the relationship and collaboration between regional and hospital doctors, thus avoiding the dichotomy between financial and supplying companies. 

An essential place is reserved for family doctors, who are considered a key point in the whole system since they hold the entire responsibility for the patient’s health. 

 

The Government has definitely passed the Legislative Decree 229 of June 19 1999 after reviewing some parts of the original scheme, which had been observed and conditioned in spite of having received favourable opinions from the Chamber and the Senate. 

 

Content of the Decree 229

 

National Health Service

 

The National Health Service is defined as the set of business functions and activities of the Regional Health Services (SSR).

 

Uniform levels of health care:

 

The uniform and essential levels of health care are defined by the National Health Plan, keeping the principle of human dignity, the health care need, the individual’s equity regarding the admission to medical health care, the quality of treatment and its suitability with regard to both the specific requirement and the savings in the use of the assets (refer to the aforementioned in point 3 of the delegation law text that refers to establishing a context between levels of health care and financial assets).

 

Socio-health integration

 

The socio-health care services, with a remarkable health care integration, are guaranteed by the Health companies within the essential levels of health care service (maternity, infancy, the elderly, the disabled, psychiatry, substance abuse, alcohol abuse, medicines, HIV, and terminal illnesses, incapacity or disability due to chronic degenerative pathologies).

The social services of health relevance are within the competence of the Communes, that provide for their financing within the framework of the regional law.

  

The new role of the local autonomies.

 

The Decree reinforces the autonomy of the Regions that are primarily responsible for administrating and organising the provision of treatment and rehabilitation services. The Regions contribute to defining the National Health Plan and to determining the comprehensive need of the National Health Service.

The Communes play a more decisive role in planning and controlling services, also in achieving objectives and controlling the General Director’s performance, as well.

The network of relationships among the Regions, the local Districts and the Local Health Units is completed with the identification of monitoring planning tasks or with the intervention of the Government invested with substitution powers that can be applied if the Regions seriously infringe the Law.

 

Practitioners’ exclusive terms of service, independent practice and retirement age.

 

Practitioners must choose between an exclusive employment relationship and the independent practice outside the National Health Service.

The employment contract sets forth a scheme of incentives and bonuses for those who choose the exclusive employment relationship. The single role of the medical directive is introduced. The two current levels become a single joint level articulated according to professional and administrative responsibilities. The Heads of Service’s responsibilities are strengthened, but they cannot remain in those positions forever. In fact, there must be a control of their performance every five years. The career will be based on their skill and responsibility.

In the case of all in-service staff or hired physicians, the retirement age limit is 65 years, which might be increased to 67.

In the case of family doctors, the agreement will establish the terms and manners of application. This limit is also valid in the case of university doctors, limited to the ordinary practice and to the management of the National Health System structures. A transient regulation provides for a gradual application.

The scope and manner of general practitioners’ and paediatricians’ independent practice of free choice, considering that the time exclusively devoted to the private practice does not hinder the correct and adequate compliance with the practitioner’s obligations, either in his practice office or at the patient’s residence.  Private practice services must be defined according to the agreement entered into. Doctors must register with the Regional Health Unit upon beginning of their independent practice, indicating place and hours of their private service in order to facilitate appropriate controls. 

 

Local prevention

 

The Prevention Department organises the set of comprehensive prevention and public health activities according to the directives of the health plan 98/2000; the Prevention Department has a role in the multilateral aspects that contribute to promoting and protecting health: from the environmental sector to the animal health area, from safety in relation to food and drink to prevention of risks at work. The Department coordinates all the monitoring and control of activities of veterinarian services.

 

Citizens’ participation.

 

Section 14 of the Decree 502/92 culminates as follows:

“The Regions consider the participation of citizens’ movements and voluntary service organisations intended to protect the right to health in activities related to planning, controlling and assessing the health care services at a regional, corporate and district level. 

 

In spite of all the even recent intentions to make it fail, the National Health Service is still a fundamental aspect of the unification of the Italian society. Our humble commitment is to contribute towards maintaining it, for everyone’s sake.