Evolution and implementation of the Italian health service reform of 1978 Mark James McCarthy A thesis submitted for the degree of Doctor of Philosophy in the University of London June 1991 Department of Social Administration London School of Economics UMI Number: U048585 All rights reserved INFORMATION TO ALL USERS The quality of this reproduction is dependent upon the quality of the copy submitted. In the unlikely event that the author did not send a complete manuscript and there are missing pages, these will be noted. Also, if material had to be removed, a note will indicate the deletion. Dissertation Publishing UMI U048585 Published by ProQuest LLC 2014. Copyright in the Dissertation held by the Author. Microform Edition © ProQuest LLC. All rights reserved. This work is protected against unauthorized copying under Title 17, United States Code. ProQuest LLC 789 East Eisenhower Parkway P.O. Box 1346 Ann Arbor, Ml 48106-1346 T hVzr-S-e ^ S D 4 0 6 7 Abstract The study seeks to answer two questions: Why and how was a national health service introduced in Italy in 1978? How, and how well, has the service worked? First proposals were made to improve public hygiene and access to health care in Italy in 1945. However, only in the 1970s was there political support for full reform. The principles of the national health service - full population cover, public funding, comprehensive services, local control - were agreed by most political parties; but there were also differences between parties over important issues. Parliament approved the law during an exceptional period in 1978 when the Christian Democrat party depended on the Communist party to sustain their government. The Servizio Sanitario Nazionale (SSN) has been implemented through the 19 regions and 2 autonomous provinces. 673 Unita Sanitarie Locale (local health units) provide the organisational structures for local management, with a wide range of services including general practice and hospital care, hygiene and prevention, occupational health and veterinary care. Terms of service are uniform across the country and negotiated nationally. About 15% of inpatient care, and about 30% of ambulatory care, is contracted to non-SSN salaried physicians. Public services in Italy are usually believed to be inferior to private services, to be excessively bureaucratic and of poor quality. Some evidence supports these perceptions, more commonly in the south than in cental or northern regions. Several features of the SSN, such 3 as national planning, prevention and occupational health, and public participation, have not developed as intended in the reform. Neverthless, the SSN has also achieved several major objectives - a public health service available to all, an acceptable mix of public and private-contractual provision, public representation through regions and communes, and national financial control. On balance, the Italian health reform of 1978 has been a success. 4 CONTENTS Introduction 17 Chapter 1 Italy 25 Chapter 2 A review of literature 2.1 Comparing welfare systems 48 2.2 Comparing health services: which is better? 57 2.3 Evaluating Health Care 66 2.4 Health services in Italy 72 Chapter 3 The development of health services in Italy 3.1 From the nineteenth century to 1945: a summary 75 3.2 1945-68: the post war period 80 3.3 1968-74: the years of delay 94 3.4 After 1974: slow completion 108 Chapter 4 The Servizio Sanitario Nazionale 4.1 Structure and functions 117 4.2 Hospitals 128 4.3 Ambulatory care 139 4.4 Primary care 146 Chapter 5 Resources 5.1 Funding the service 158 5.2 Distribution of health care resources 165 5.3 Private medicine 175 .5.4 Planning health services 181 5.5 Education 194 6 Chapter 6 The health of Italians 6.1 Demography 207 6.2 Special groups 221 6.3 Population surveys 240 Chapter 7 Special services 7.1 Mental health 249 7.2 Occupational health 260 7.3 Tobacco, alcohol and drugs 272 Chapter 8 Evaluation - the Servizio Sanitario Nazionale in review 8.1 Effectiveness 297 8.2 Efficiency 306 8.3 Equity 324 8.4 Acceptability 335 8.5 The mental health reform 344 Chapter 9 Hopes fulfilled? 9.1 Evaluation from a U.K. perspective 351 9.2 Further reform 367 Bibliography 376 7 TABLES Table 4.1 Party representation on USL management committees. Table 4.2 Distribution of USLs by resident population. Table 4.3 Staff in an average USL directly employed by SSN. Table 4.4 Staff per 1000 population in regions, 1984. Table 4.5 Inpatient admission rates by country, 1990. Table 4.6 Inter-regional flows of hospital patients, 1987. Table 4.7 Residence of discharged patients treated in Emilia Romagna. Table 4.8 Distribution of public and private beds by region, 1987. Table 4.9 Selected indices of public and private hospitals, 1987. Table 4.10 Admissions and lengths of stay in public and private hospitals by specialty, 1984. Table 4.11 Contracted expenditure for ambulatory care, 1984. Table 4.12 Ambulatory specialist clinics in public and private ownership, 1987. Table 4.13 Range of hours of specialty consultation by region, 1980. Table 4.14 Specialist visits per 1000 population, Emilia Romagna, 1982. Table 4.15 Consultations in general practice: proportions by age and sex. Table 4.16 Services provided by GPs by disease group. Table 4.17 Net practice income of GPs for selected countries. Table 5.1 Coverage for health insurance by nine main schemes, 1972. Table 5.2 Population covered by Hutue health insurance at 1980. Table 5.3 Health insurance contributions, 1986. Table 5.4 Financing of the national health fund 1981-87. Table 5.5 Cost containment legislation 1978-86. Table 5.6 Regional allocations of national health fund per capita 8 and percentage compared with all Italy. Table 5.7 Comparison of spending of main headings of national health fund in regions in 1988. Table 5.8 Public current health expenditure, 1987. Table 5.9 Changes in spending on contractual and private health care, 1977-81. Table 5.10 Regional expenditure per inhabitant for contractual hospital care, 1987. Table 5.11 Privately financed health expenditure, 1987. Table 5.12 Monthly spending on health care by social group. Table 5.13 Private health insurance coverage by educational status. Table 5.14 Regional planning at 31 December 1987. Table 5.15 Headings for sections of regional health plan, Campania, November 1984. Table 5.16 Proposed changes in hospital provision, Veneto region. Table 5.17 Proposed changes in budgets, Veneto region. Table 5.18 Concentration of doctors in provincial capitals, 1984. Table 5.19 Medical migration within the European Community 1977-86. Table 5.20 Doctors' specialist certificates, 1978. Table 5.21 Activities of doctors in SSN, 1980. Table 6.1 Birth and death rates for selected regions. Table 6.2 Population projections to 2011, Italy. Table 6.3 Expectation of life 1960-62 and 1983, Italy. Table 6.4 Causes of death of people under 75 years, Italy, 1980. Table 6.5 Death rates per 10 000 population under 75, Italy, 1980. Table 6.6 Deaths by main groups of causes, Italy, 1975-87 Table 6.7 Infant and perinatal mortality rates, selected European 9 countries 1980. Table 6.8 Age standardised death rates per 100 000 for selected disease categories, 1981. Table 6.9 Perinatal mortality, selected countries, 1950-1984. Table 6.10 Infant mortality, selected countries, 1950-1987. Table 6.11 Range of annual notifications of infectious disease cases in Italy. Table 6.12 Occupational accidents and diseases accepted for compensation, 1987. Table 6.13 Methods used in completed suicide in young and old, 1982. Table 6.14 Broad categories of ill health given in 1983 morbidity survey. Table 6.15 Social grouping in Italy compared with British social class. Table 6.16 Self perceived state of health by social group, 1983. Table 6.17 Self perception of health by broad regions, 1983. Table 6.18 Perception of disability by social group, 1980. Table 6.19 Place of self reported accidents by age group, 1980. Table 6.20 Place of self reported accidents by broad region, 1980. Table 6.21 Hospital admission by social group, 1980. Table 6.22 Use of diagnostic tests by social group, 1980. Table 6.23 Use of diagnostic tests by broad region, 1980. Table 6.24 Use of health service for minor illness by social group. Table 6.25 Using a private doctor by social group. Table 7.1 Public and private psychiatric hospital beds, Italy, 1977 and 1987. Table 7.2 Psychiatric services by region, 1987. 10 Table 7.3 Scheme for workers' evaluation of health hazards. Table 7.4 Tobacco production in selected countries, 1987. Table 7.5 Changing smoking habits, Italy, 1980-83. Table 7.6 Main wine producing regions, 1983, and land use for vines, 1982. Table 8.1 Expectation of life at birth, 40 years and 60 years, Italy, 1970 and 1980. Table 8.2 Infant mortality by reqion, 1968, 1980 and 1987. Table 8.3 Positive answers to the question: Do you have need of any of the following services?' Table 8.4 Expenditure as proportion of GDP, selected countries. Table 8.5 Beds in general hospitals, selected regions, 1968-87. Table 8.6 Throughput in general hospital beds in 5 regions, 1968 and 1984. Table 8.7 Personnel in public hospitals, 1976, 1984, 1987. Table 8.8 Changes in use of hospital beds, Emilia Romagna, 1976 and 1982. Table 8.9 Health insurance fund spending for different insured groups by health care sector. Table 8.10 Stillbirth rates per 1000 births 1955-59, 1975-79 by social group. Table 8.11 Perceptions of public and private hospitals: care.