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.Print