The Italian healthcare system on the eve of the pandemic ESPN Flash Report 2020/20

EMMANUELE PAVOLINI – EUROPEAN SOCIAL POLICY NETWORK APRIL 2020

The present report assesses the state of Description the Italian national expenditure is driven by innovations in healthcare system Over the last two decades (from 2000 to machinery for diagnosis and treatment, (NHS), with its 2018), public spending on healthcare in as well as by new drugs, which improve strengths and has increased. However, this the quality of care and, often, of life. weaknesses, on the eve increase occurred substantially in the of the pandemic. The first decade of the 21st century, whereas As a consequence, healthcare workers Italian NHS has in the last decade there were first cuts and some social groups (in particular provided and continues and then a stagnation in levels of low-income households) have been to provide a good spending, which have not returned to paying in recent decades (especially the last decade) for a system that holds up quality of care. pre-crisis levels, according to the OECD. However, it has three Importantly, in the last decade, public in terms of performance, but is suffering weak points which have healthcare expenditure declined in from declining (and by now scarce) become critical with the relation to GDP – from 7.0% (2010) to financial resources. As regards pandemic: the limited 6.5% (2017) - in contrast with the healthcare workers, new hiring was financial resources general stable level in the EU-15 (8.2%). halted at the time of austerity, which made available to the aggravated two main features of the NHS, the excessive load Even more worryingly, Italy lost ground NHS: the scarcity of nurses, and an on the shoulders of over the past two decades compared to ageing and shrinking medical workforce. health professionals most of the other EU-15 countries. Even Compared to most Central-Northern EU (doctors, nurses and in 2000, per capita public expenditure on countries, Italy has far fewer people other professionals), was about 9% lower employed in the healthcare and social and inequalities in than the average level in the EU-15 care sector. Furthermore, specifically in access to services. countries. In other words, in 2000, for the health sector, there are relatively fewer nurses, and although the number every €100 spent on public health for each citizen in the EU-15, Italy spent of doctors is similar to other countries, €91. The situation deteriorated in the these doctors are older: more than half of Italian doctors are over 55 years old. years of the crisis and, in 2018, Italy spent over a quarter less for each Italian resident than the EU-15 average. In addition, the low per capita public health expenditure (compared with most Although the efficiency of the NHS has EU-15 countries) has resulted in a improved, public healthcare spending greater outlay of resources by citizens – growth in Italy has not been able to keep i.e. larger out-of-pocket payments. This, up with two trends that cannot be alongside a higher incidence of private LEGAL NOTICE tackled with merely a more efficient use healthcare expenditure than elsewhere This document has been of resources. The first is population in the EU-15 (apart from Greece), has prepared for the European Commission. However, it ageing: since a large share of health resulted in a larger share of the reflects the views only of the expenditure is concentrated on older population - especially low-income authors, and the Commission segments of the population (even before households - reporting unmet medical cannot be held responsible for coronavirus), if the percentage of elderly needs for reasons of cost (including co- any use which may be made of the information contained people increases, then needs increase payments), distance or waiting lists. In therein. and expenditure should also increase. 2018, 4.8% of individuals in the first The second is technology: part of the income quintile declared that they had

such unmet needs, as opposed to With the dramatic and unexpected much remains to be done to ensure 2.0% in the EU-15 (Eurostat). (for almost all health experts) appropriate public intervention. arrival of the coronavirus, Italy However, the issue of spending Furthermore, problems of access found itself: remains pivotal. to and quality of healthcare in Italy vary by geographical area, with the a) with relatively few hospital regions of in general beds – just like many other significantly more disadvantaged countries, with Germany Further reading than those of the Centre-North. being one of the main exceptions; Italian Senate (2018), Documento conclusivo Outlook and b) without an adequate supply dell’indagine conoscitiva sulla commentary of residential and regional sostenibilità del servizio healthcare facilities and sanitario nazionale [Final Report on the Sustainability of the Realistically, until a few months services; Italian NHS], January 2018. ago very few healthcare c) with a decreasing number Osservasalute (2019), Rapporto stakeholders, if any, thought that of doctors and a long- Osservasalute 2018: Stato di the challenge to the Italian NHS standing scarcity of nurses. would come from an epidemic (let salute e qualità dell’assistenza alone a pandemic). The main These conditions of the NHS (and nelle regioni italiane concern was the need to of the long-term care system), [Osservasalute Report 2018 on strengthen the care system, not so combined with a large elderly the health and healthcare situation in the Italian regions], much with respect to acute cases population (22.7% of were Osservasalute, Rome. (many improvements have been 65 years or older in 2019), have made in this respect in recent been two very critical aspects Pavolini, E. (2020), La sanità decades) but rather for the which have made it more difficult italiana di fronte alla crisi del treatment of chronic diseases. In to tackle the coronavirus. Coronavirus [The Italian recent decades, chronic needs healthcare system facing the have grown considerably. It is crucial that Italy should Coronavirus crisis], OCIS Note Therefore, the logic behind reforms strengthen its NHS, and this No. 3, to many Western healthcare cannot be done without increasing https://osservatoriocoesionesoci systems has been: fewer hospital public expenditure on healthcare. ale.eu/wp- beds, more outpatient/specialist The efficiency of the NHS can be content/uploads/2020/03/Nota1 _Pavolini_2020.pdf. activities, more residential facilities further improved, but managerial (for example, nursing homes) and and professional performance is Author more home care. From this point of already good, if not excellent, as view, Italy was not able to make also acknowledged by the OECD. Emmanuele Pavolini (University the transition and remained half- Right now, what is needed are of Macerata) way through the process. Hospital more economic resources, for hiring more staff as well as departments have been closed down, but in some of the country maintaining/expanding services (especially the Centre-South), the and facilities. Undoubtedly, the healthcare system outside effectiveness and efficiency of the hospitals has not been adequately NHS are higher in Central-Northern strengthened. Italy than in Southern Italy, where

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Quoting this report: Pavolini, Emmanuele (2020). The Italian healthcare system on the eve of the pandemic, ESPN Flash Report 2020/20, European Social Policy Network (ESPN), Brussels: European Commission.