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A Framework for Assessing Priority in Health Investments Needed in Italy Under the Programming Period 2021/2027 of the Cohesion Policy

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A Framework for Assessing Priority in Health Investments Needed in Italy Under the Programming Period 2021/2027 of the Cohesion Policy A framework for assessing priority in health investments needed in Italy under the programming period 2021/2027 of the Cohesion Policy Prepared by: Prof. Milena Vainieri, Dr. Ylenia Sacco and Dr. Francesca Ferrè Francesca Ferrè EXPERT CONTRACT NUMBER – 2020CE16BAT064; AMI expert reference: REGIO 2020-0446 Ylenia Sacco EXPERT CONTRACT NUMBER – 2020CE16BAT066; AMI expert reference: REGIO 2018-0154 Milena Vainieri EXPERT CONTRACT NUMBER – 2020CE16BAT065; AMI expert reference: REGIO 2020-0447 Version 21st August 2020 Introduction As declared by the European Council Recommendation on the 2019 National Reform Program of Italy and on the 2019 Stability Programme (pg. 12) “The outcome of the health system is overall good, despite below-Union average spending. Nevertheless, the provision of healthcare largely varies across regions, affecting access, equity and efficiency, and could be improved through better administration and by monitoring the delivery of standard levels of services. More home and community-based care and long-term care is key to provide support to people with disabilities and other disadvantaged groups”. The abovementioned assessment refers to the Italian healthcare system before the unprecedented emergency of the COVID-19 pandemic that hit countries worldwide in the first months of 2020. The Italian health system was put under significant strain, evidencing weaknesses and challenges in crisis preparedness especially due the health system governance fragmentation and highlighting gaps in health and social system integration and service digitalization. These challenges do not characterized just some Italian regions but cut across regional health systems with different degree of preparedness. Overall, the health emergency has shifted health investments at the top of the Policy Objective (PO) 4 of the Cohesion Policy (a More Social Europe). Long-term investments are required to recover and make the health system more resilient and sustainable. A proper identification of investment needs and priorities at regional level is therefore needed to ensure an effective use of EU funding opportunities. This document provides a conceptual framework for identifying specific evidence-based healthcare investment needs and gaps. The proposed framework will be use as a reference by the experts for advising on regional level unmet healthcare infrastructure. This framework is the result of the joint effort of the three experts. Italian National (and Regional) Health Service(s) 1 The Italian National Health System (NHS), which follows the Beveridge model, is a public health system that provides universal coverage for comprehensive and essential health services through general taxation. Since the early 1990s, a strong decentralization policy has been adopted and the central government has gradually transfer fiscal, financial and organizational autonomy to the 20 Regions. At national level, the Ministry of Health (supported by several specialized agencies) sets the fundamental principles and goals of the health system, determines the core benefit package of health services guaranteed across the country (know as “Essential Level of Care”), and allocates national funds to the Regions. The regions are responsible for organizing and delivering health care. As reported in the Italian health system review of the European Observatory on Health Systems and Policies “Now most health policies are developed and implemented by Regions, with an increasing heterogeneity of institutional arrangements, provider payment rules and levels of performance in terms of the quantity and quality of care offered to citizens.” The last financial and fiscal crisis has exacerbated the regional fragmentation while highlighting the need of a central financial control. Indeed, the central government maintained a guiding role in controlling the financial sustainability of health care expenditures at both national and regional level (also through caps to specific inputs such as personnel expenditure) with a strong role of the Ministry of Finance. Meanwhile the Ministry of Health introduced monitoring the Essential Level of Care (“griglia LEA”) on a yearly base using around 30 performance indicators covering Public Health, Acute care, Primary and Secondary care. Figure 1 reports the overall score of Regions on the monitored indicators from 2012 to 2017. The last available scores are those of 2018 that reports overall improvements for almost all the Regions. If Regions are able to fulfil the standards of care and financial viability they can have access to an extra fund (“fondo premialità”) which is the 3% of the total national health fund. Figure 1. The overall score of the Essential Level of Care. 2 Source: Ministry of Health. Minimum level is a score of 130 up to 2015, then the minimum level has been increased to 160 points. Despite the overall improvement obtained thanks to the monitoring and control of the Essential Level of Care and the introduction of the National Outcome Program (PNE, Programma Nazionale Esiti) that provides support for audit purposes on outcome indicators, yet there are differences across Regions in terms of access and level of care provided (see the last paragraph). Method to design the conceptual framework From a methodological point of view, to design the framework, we followed two steps: i) a review of the principal documents and articles on this topic; ii) a face-to-face validity of the framework with key informants of the national health care system. In particular, for the review we analysed: • All the opinions of the Expert Panel on effective ways of investing in Health (EXPH) • Selected recent documents from the OECD and the European Commission on health system challenges and opportunities; • Key peer-reviewed articles on the topic of health care system performance assessment and digital transformation in the healthcare domain; • The main national health strategic documents such as national plan for health and digital transformation, national chronic care plan, etc; • Selected documents and reports on COVID and post-COVID such as the “Iniziative per il rilancio Italia 2020-2022” also named “Piano Colao” to face the economic crisis coming from the coronavirus outbreak and the Decreto Rilancio converted in law (Kick-start law of the July 17, 2020) the latest national intervention to tackle the economic consequences of the COVID emergency. The list of articles and documents reviewed are shown in appendix 1. For the face-to-face validity of the framework analysed we made in-depth interviews with national key informants with different background: • a responsible for the health information system • a professor in management in healthcare • a former chief executive officer of a northern Italian health authority with a medical background To collect evidence-based statistics and indicators on the dimensions listed in the framework and provide regional-based investment priorities we will use the following sources: • Population health status: ISTAT Health for All database (National Statistical Institute https://www.istat.it/it/archivio/14562), Indagine PASSI (Istituto Superiore di Sanità https://www.epicentro.iss.it/passi/dati/attivita?tab-container-1=tab1) and IRPES (Inter- regional performance evaluation system managed by Laboratorio Management & Sanità Scuola Superiore Sant’Anna https://performance.santannapisa.it/pes/start/start.php). 3 • Quality, access, responsiveness/ patient-centred care and appropriateness: Monitoraggio dei LEA c.d. “Griglia LEA” (Ministero della Salute http://www.salute.gov.it/imgs/C_17_pubblicazioni_2832_allegato.pdf), Nuovo Sistema di Garanzia (Ministero della Salute http://www.salute.gov.it/portale/lea/dettaglioContenutiLea.jsp?lingua=italiano&id=5238&ar ea=Lea&menu=monitoraggioLea), Rapporto SDO (Ministero della Salute http://www.salute.gov.it/imgs/C_17_pubblicazioni_2898_allegato.pdf), IRPES (Inter- regional performance evaluation system managed by Laboratorio Management & Sanità Scuola Superiore Sant’Anna https://performance.santannapisa.it/pes/start/start.php); The tree-map selection of the National Outcome Program (PNE) https://www.agenas.gop.it/programma-nazionale-esiti-pne/indicatori-pne • Human resources (healthcare workforce): Annuario Statistico (Ministero della Salute http://www.salute.gov.it/imgs/C_17_pubblicazioni_2879_allegato.pdf). • Physical resources (infrastructure / health equipment and diagnostics): Annuario Statistico (Ministero della Salute) and analysis of regional healthcare financial statement available online (Openbdap Corte dei Conti/Ragioneria Generale dello Stato https://openbdap.mef.gov.it/) • ICT and e-health: AGID (Agenzia per l’Italia Digitale https://www.agid.gov.it/it/piattaforme/sanita-digitale), Ministero della Salute (http://www.salute.gov.it/portale/temi/p2_4.jsp?lingua=italiano&tema=Ricerca%20e%20inn ovazione&area=eHealth), IRPES (Inter-regional performance evaluation system managed by Laboratorio Management & Sanità Scuola Superiore Sant’Anna https://performance.santannapisa.it/pes/start/start.php). The conceptual framework The model proposed is based on the OECD conceptual framework that covers the main concepts and areas of performance in health (Arah et al 2006, International Journal for Quality in Health Care) focusing on the quality of health care using a broader perspective on health and its other determinants to capture population health. Health and health care performance is determined by multiple interdependent factors, including population health status, non-health
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