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The reform of the Italian Constitution and its possible impact on public health and the National Health Service
Accepted Manuscript Title: THE REFORM OF THE ITALIAN CONSTITUTION AND ITS POSSIBLE IMPACT ON PUBLIC HEALTH AND THE NATIONAL HEALTH SERVICE Author: C Signorelli PII: DOI: Reference:
S0168-8510(16)30274-3 http://dx.doi.org/doi:10.1016/j.healthpol.2016.10.008 HEAP 3642
To appear in:
Health Policy
Author: GM Fara PII: DOI: Reference:
S0168-8510(16)30274-3 http://dx.doi.org/doi:10.1016/j.healthpol.2016.10.008 HEAP 3642
To appear in:
Health Policy
Author: A Odone PII: DOI: Reference:
S0168-8510(16)30274-3 http://dx.doi.org/doi:10.1016/j.healthpol.2016.10.008 HEAP 3642
To appear in:
Health Policy
Author: A Zangrandi PII: DOI: Reference:
S0168-8510(16)30274-3 http://dx.doi.org/doi:10.1016/j.healthpol.2016.10.008 HEAP 3642
To appear in:
Health Policy
Received date: Accepted date:
26-8-2016 16-10-2016
Please cite this article as: Zangrandi A.THE REFORM OF THE ITALIAN CONSTITUTION AND ITS POSSIBLE IMPACT ON PUBLIC
HEALTH AND THE NATIONAL HEALTH http://dx.doi.org/10.1016/j.healthpol.2016.10.008
SERVICE.Health
Policy
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Title:
THE REFORM OF THE ITALIAN CONSTITUTION AND ITS POSSIBLE IMPACT ON PUBLIC HEALTH AND THE NATIONAL HEALTH SERVICE
Authors: C Signorelli1,2, GM Fara3, A Odone1, A Zangrandi4
Affiliations: (1) Department of Biomedical, Biotechnological and Translational Sciences, University of Parma, Italy & School of Medicine, University Vita-Salute San Raffaele, Milan, Italy (2) President, Italian Society of Hygiene, Preventive Medicine and Public Health (SItI) (3) Department of Public Health and Infectious Diseases. Sapienza University, Rome, Italy (4) Department of Economics, University of Parma, Italy
Article type: Letter to the Editor Word count: 559
Corresponding author: Carlo Signorelli Unit of Public Health Department of Biomedical, Biotechnological and Translational Sciences. University of Parma. Via Volturno, 39, 43125 Parma, Italy. phone: +39 (0521) 033795 E-mail: [email protected]
The new Italian Consitutional reform, approved by the Parliament last April, 12th and submitted to a popular referendum scheduled for fall 2016 (1) has further stimulated the ongoing debate on the sustainability of the Italian National Health Service (INHS), recently addressed by Longo (2). The proposed amendments to the Constitution to eliminate concurrent legislative powers (Article 117), which were introduced in the 2001 reform (35), do not eliminate - for the healthcare sector - a split of competences between the state and the 19 Italian regions and 2 autonomous provinces (R&AP). In the new reform the state legislative powers include the definition of the "Essential levels of care” (LEA): the general and common provisions for health protection and social services, for food safety, and for workers’ prevention and safety. The R&AP legislative powers include the planning and the organization of health and social services (5). The statements of the revised Article 117 of the Constitution appear to be rather generic. Yet, in theory, the impact of the reform will not be disruptive compared to the current organization of the INHS which – most importantly will remain one of the few health systems in OECD countries to mantain universal health care coverage supported by general taxation (2). And while it is clear that, from a political point of view, the constitutional reform goes in the direction of a renewed centralism, some recently approved laws had already taken the ‘centralization’ pathway; this according with the Pact for Health (Patto per la salute), a three year programmatic plan (2014-16) jointly approved by the state and all regional governments in the State-Regions Conference (5). In fact, as for now, R&AP-level health policy is already strongly influenced by the rules set at the central level, these mainly aiming to create economic
sustainability and quality of performances. The demand for greater monitor and evaluation, minimum standards, and the centralization of certain activities should be already fully implemented with the endorsement of all R&AP (6). Our prevision is that, in case of approval of the proposed constitutional reform, there will be a greater boost to legislative initiatives on health by the Parliament and the government (in particular the Ministry of Health and the Ministry of Finance), even if the entire framework of relations between the state and the R&AP will be revisited in the light of the powers of the new Senate and the possible downsizing of the State-Regions Conference which might cause delays, disputes and the emerging need for new specific regulations. The field of prevention and public health seems to be affected by the reform which enhances the state legislative powers, but not necessarily the central management. However, the overall structure of the INHS - that no political party apparently wants to disrupt - should not undergo upheavals after the referendum, unless there is political exploitation, especially in the case of rejection at the referndum of the constitutional amendments voted by the Parliament. Therefore, at this stage, we believe of crucial importance that the government and Parliament keep sustaining and supporting the INHS, starting from the approval of the new Essential levels of care (LEA) and the law on professional liability, both currently under parlamentary discussion. Full implementation of the already existing laws and regulations (that go in the direction of reinforced INHS sustainability), would already help to reduce expenses, inappropiate health performances, and waste.
References
1.
TIME. Italy’s Parliament Votes Yes on Historic Constitutional Reform. 23 April 2016. Available at http://time.com/4291740/italian-constitution-reform-matteo-renzi/
2.
Longo F. Lessons from the Italian NHS retrenchment policy. Health Policy. 2016 Mar;120(3):306-15.
3.
Keating, M. and A. Wilson (2010), “Federalism and Decentralisation in Italy”, PSA Conference Paper. Available at http://scienzepolitiche.unical.it.
4.
OECD (2014). OECD Reviews of Health Care Quality: Italy 2014 Raising Standards, OECD publishing DOI:10.1787/9789264225428-en.
5.
Ferré F, de Belvis AG, Valerio L, Longhi S, Lazzari A, Fattore G, Ricciardi W, Maresso A. Italy: Health System Review. Health Systems in Transition, 2014, 16 (4):1–168.
S0168-8510(16)30274-3 http://dx.doi.org/doi:10.1016/j.healthpol.2016.10.008 HEAP 3642
To appear in:
Health Policy
Author: GM Fara PII: DOI: Reference:
S0168-8510(16)30274-3 http://dx.doi.org/doi:10.1016/j.healthpol.2016.10.008 HEAP 3642
To appear in:
Health Policy
Author: A Odone PII: DOI: Reference:
S0168-8510(16)30274-3 http://dx.doi.org/doi:10.1016/j.healthpol.2016.10.008 HEAP 3642
To appear in:
Health Policy
Author: A Zangrandi PII: DOI: Reference:
S0168-8510(16)30274-3 http://dx.doi.org/doi:10.1016/j.healthpol.2016.10.008 HEAP 3642
To appear in:
Health Policy
Received date: Accepted date:
26-8-2016 16-10-2016
Please cite this article as: Zangrandi A.THE REFORM OF THE ITALIAN CONSTITUTION AND ITS POSSIBLE IMPACT ON PUBLIC
HEALTH AND THE NATIONAL HEALTH http://dx.doi.org/10.1016/j.healthpol.2016.10.008
SERVICE.Health
Policy
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Title:
THE REFORM OF THE ITALIAN CONSTITUTION AND ITS POSSIBLE IMPACT ON PUBLIC HEALTH AND THE NATIONAL HEALTH SERVICE
Authors: C Signorelli1,2, GM Fara3, A Odone1, A Zangrandi4
Affiliations: (1) Department of Biomedical, Biotechnological and Translational Sciences, University of Parma, Italy & School of Medicine, University Vita-Salute San Raffaele, Milan, Italy (2) President, Italian Society of Hygiene, Preventive Medicine and Public Health (SItI) (3) Department of Public Health and Infectious Diseases. Sapienza University, Rome, Italy (4) Department of Economics, University of Parma, Italy
Article type: Letter to the Editor Word count: 559
Corresponding author: Carlo Signorelli Unit of Public Health Department of Biomedical, Biotechnological and Translational Sciences. University of Parma. Via Volturno, 39, 43125 Parma, Italy. phone: +39 (0521) 033795 E-mail: [email protected]
The new Italian Consitutional reform, approved by the Parliament last April, 12th and submitted to a popular referendum scheduled for fall 2016 (1) has further stimulated the ongoing debate on the sustainability of the Italian National Health Service (INHS), recently addressed by Longo (2). The proposed amendments to the Constitution to eliminate concurrent legislative powers (Article 117), which were introduced in the 2001 reform (35), do not eliminate - for the healthcare sector - a split of competences between the state and the 19 Italian regions and 2 autonomous provinces (R&AP). In the new reform the state legislative powers include the definition of the "Essential levels of care” (LEA): the general and common provisions for health protection and social services, for food safety, and for workers’ prevention and safety. The R&AP legislative powers include the planning and the organization of health and social services (5). The statements of the revised Article 117 of the Constitution appear to be rather generic. Yet, in theory, the impact of the reform will not be disruptive compared to the current organization of the INHS which – most importantly will remain one of the few health systems in OECD countries to mantain universal health care coverage supported by general taxation (2). And while it is clear that, from a political point of view, the constitutional reform goes in the direction of a renewed centralism, some recently approved laws had already taken the ‘centralization’ pathway; this according with the Pact for Health (Patto per la salute), a three year programmatic plan (2014-16) jointly approved by the state and all regional governments in the State-Regions Conference (5). In fact, as for now, R&AP-level health policy is already strongly influenced by the rules set at the central level, these mainly aiming to create economic
sustainability and quality of performances. The demand for greater monitor and evaluation, minimum standards, and the centralization of certain activities should be already fully implemented with the endorsement of all R&AP (6). Our prevision is that, in case of approval of the proposed constitutional reform, there will be a greater boost to legislative initiatives on health by the Parliament and the government (in particular the Ministry of Health and the Ministry of Finance), even if the entire framework of relations between the state and the R&AP will be revisited in the light of the powers of the new Senate and the possible downsizing of the State-Regions Conference which might cause delays, disputes and the emerging need for new specific regulations. The field of prevention and public health seems to be affected by the reform which enhances the state legislative powers, but not necessarily the central management. However, the overall structure of the INHS - that no political party apparently wants to disrupt - should not undergo upheavals after the referendum, unless there is political exploitation, especially in the case of rejection at the referndum of the constitutional amendments voted by the Parliament. Therefore, at this stage, we believe of crucial importance that the government and Parliament keep sustaining and supporting the INHS, starting from the approval of the new Essential levels of care (LEA) and the law on professional liability, both currently under parlamentary discussion. Full implementation of the already existing laws and regulations (that go in the direction of reinforced INHS sustainability), would already help to reduce expenses, inappropiate health performances, and waste.
References
1.
TIME. Italy’s Parliament Votes Yes on Historic Constitutional Reform. 23 April 2016. Available at http://time.com/4291740/italian-constitution-reform-matteo-renzi/
2.
Longo F. Lessons from the Italian NHS retrenchment policy. Health Policy. 2016 Mar;120(3):306-15.
3.
Keating, M. and A. Wilson (2010), “Federalism and Decentralisation in Italy”, PSA Conference Paper. Available at http://scienzepolitiche.unical.it.
4.
OECD (2014). OECD Reviews of Health Care Quality: Italy 2014 Raising Standards, OECD publishing DOI:10.1787/9789264225428-en.
5.
Ferré F, de Belvis AG, Valerio L, Longhi S, Lazzari A, Fattore G, Ricciardi W, Maresso A. Italy: Health System Review. Health Systems in Transition, 2014, 16 (4):1–168.