Rediscovering the roots of public health services. Lessons from Italy
The major cuts of recent decades have not erased the considerable achievements of Italy’s public health services.
In these dark days of the coronavirus pandemic, our screens are often filled with images of people applauding health personnel outside hospitals – a striking recognition of how crucial public health has become for our individual and collective destiny. Revisiting the history of these public health services is essential to understanding not only the ‘frontlines’ of the fightback against the pandemic, but also the institutions, policies and resources that make such a fight feasible.
In this perspective the case of Italy is of particular interest, not only because of the scale of the pandemic it has had to face before other European countries, but also because of the history of its public health service, rooted in a major transformation, driven by the clear vision of key experts, a solid commitment by left parties and the wideranging mobilisation of trade unions and social activists. The outcome – the 1978 reform – was a universal, public, free health service, offering a wide range of provision outside the market, largely modelled on the British NHS and reflecting the definition of health spelt out by the WHO in 1946.
Italy is a major case of policy success in health. According to the 2017 OECD data, life expectancy at birth in Italy is 83.1 years, compared to the 80.9 years of the European Union average: but the total health expenditure per inhabitant is 2,483 euros, against 2,884 of the average EU (a 15% gap). It is a paradox worth probing that the European country with the longest life expectancy has achieved this result with reduced spending. ).
It is a paradox worth probing that the European country with the longest life expectancy has achieved this result with reduced spending.
Servizio Sanitario Nazional
At the core of Italy’s health success lies its public health system – Servizio Sanitario Nazionale, (SSN) – which, however, has suffered major cuts in the last three decades. Considering public health expenditure only, in Italy they amount to 6.5% of GDP, in line with the OECD average, but in per capita terms the SSN spends half the amount of Germany. Calculating expenditures in real terms, net of inflation, after an increase in line with other countries until 2009, per capita resources for Italian public health in 2018 had fallen by 10% over a decade, while in France and Germany they increased by 20%. This reduction is the effect of austerity policies introduced since the 2008 crisis, but it also reflects the neoliberal counter-revolution of past decades, with its push towards privatizing services and turning health into a commodity.
Another Italian paradox is that the public health reform was achieved in 1978, when in other countries welfare services started to be the targets of cuts and retrenchment. The birth of Italy’s SSN was a statement of important principles; the health reform act asserted that "the Republic protects health as a fundamental individual right and collective interest through the National Health Service", which is defined as the set of “functions, structures, services and activities intended for the promotion, maintenance and recovery of the physical and mental health of the entire population without distinction of individual or social conditions and in ways that ensure citizens' equality towards the service.”
In fact, the introduction of the public health system was the result of a twenty-year process that reflected the social transformation of the country, the opening for progressive reforms, the emergence of new subjectivities and conflicts over health and social reproduction. Unprecedented political and participatory practices, a strong intellectual ferment, workers’ activism on occupational health and social pressure from below, all contributed to shape Italy’s public health reform.
A well known example is that of the mental health reform that was pioneered – at the international level – through the activities of the group around psychiatrist Franco Basaglia who first experimented with the closing down of mental hospitals (see the book by John Foot, and the text by Franco Rotelli). In several other areas – occupational health, women’s health, drug treatments - new knowledge on illness prevention, new practices of service delivery and innovative institutional arrangements emerged, with a strong emphasis on territorial services addressing together health and social needs.
Italy’s health reform put regions at the centre of the SSN, with the possibility of adapting service provision to local needs.
The intellectual guidance for Italy’s health reform came from personalities that combined strong competence and political commitment. Besides Franco Basaglia and his work on radical psychiatry, Giulio Maccacaro was the founder of ‘Medicina Democratica’, a radical health movement; Giovanni Berlinguer was a scientist and member of parliament for the Communist Party; Alessandro Seppilli was a public health specialist and Socialist mayor of the city of Perugia; Laura Conti was a key figure of the Socialist Party and pioneered the Italian environmental movement; Ivar Oddone was an occupational physician and a former partisan – he inspired a character in Italo Calvino’s first book.
Out of their work, an integrated vision of health – physical and psychic, individual and collective, linked to the community and the territory – emerged. A new, less hierarchical type of doctor-patient relationship was proposed; the model of a decentralized health organization was introduced, with elements of participation; the centrality of preventive medicine over cure was emphasised. As Giulio Maccacaro had argued in 1976, the strategy was a bottom-up “politicization of medicine”, challenging the way industrial capitalism was exploiting workers and undermining health and social conditions in the country.
The strategy was a bottom-up “politicization of medicine”, challenging the way industrial capitalism was exploiting workers and undermining health and social conditions in the country.
This political strategy viewed health as combining a collective dimension and an individual condition; collective struggles were therefore needed to address the economic and social roots of disease and public health problems. This approach was paralleled by the feminist movement in addressing women's health issues, including the important experiments in self-organized health clinics.
Abandoning the tradition of a corporatist health system with its limited coverage of separate professional groups, Italy’s reform introduced a public and universal health service, financed through general taxation, freely available to all – not just to Italian citizens, but to all those living in the country.
The pressure for health care reform was born from an unprecedented alliance between left political forces, advanced experiences renewing medical practice, radical health activism, struggles by trade unions, workers’ groups, student and feminist movements. Here lies the originality of the Italian case, and the resilience of a strong public health model – with a large supportive consensus from citizens – in spite of decades of ‘managerial reforms’, cutbacks of funds and privatisation efforts.
Facing the pandemic
Such actions – documented by a recent history of Italy’s health service – have indeed lowered the standards of service, introduced ‘tickets’ paid for by patients, and led to a highly uneven capacity of services across Italy’s regions.
Facing the coronavirus pandemic, the strength of Italy’s public health system has emerged as a key tool for coping with the emergency. The same applies to other European countries with strong public health systems.
One of the first actions by the Italian government on March 17, 2020, when the pandemic broke out, was to increase funds for the health emergency by 3 billion euros and to hire 20,000 doctors, nurses and supporting staff. This was a recognition of past policy mistakes – cutbacks, privatisation and commodification – and of the need to fully recognise the role of universal public health as an alternative to market provision.
Moreover, the coronavirus pandemic has made visible the need for a supranational approach to public health, starting with a closer European cooperation, and addressing the need for expanding the role and funds of the WHO, with the aim of providing health as a global public good.
In this perspective, the fight against the pandemic and the importance of public health provide a space for repoliticizing society, with a common project for changing existing power relations and prefiguring alternative forms of social and economic organization, where the connections between freedom and equality can be re-established.
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