Per aspera ad astra: l’Italia e il Covid-19

The current crisis is an unprecedented global challenge in terms of its health, economic, social, and geopolitical impact. As we write, more than 4 billion people in over 100 countries are still living in some sort of lockdown. Each country has chosen its own strategy, adopting a variety of measures in an attempt to fight an unparalleled menace. Political decisions regarding population containment and border closures undeniably play an important role in the match against this epidemic.

Specific features of different healthcare systems appear to greatly impact each country’s capacity to face the epidemic. As the emergency spreads across the globe, health systems are facing enormous pressure to both manage COVID-19 patients and maintain essential services. Hit by an unprecedented stress test, the systems need to ensure they have well-functioning plans to deal with i) the outbreak, including provisions for increased numbers of staff, hospital beds, and supplies, and ii) the post-outbreak, restoring the same levels of quality and quantity to non-COVID-19 patients who, in the meantime have been left behind by the emergency.

Italy, as the first Western democracy that has faced this unparalleled battle, provides a unique opportunity to reflect on those lessons, lessons that will also impact how to return to a new “normality” that is likely to be very different from the one we have lost.

The Italian experience has already been used to highlight the drawbacks and limitations of a country’s response, suggesting that other countries should “learn from Italy’s mistakes”. It has been argued that specific aspects of the Italian context have led policy makers to commit numerous errors in managing the pandemic, leading the country into disaster.  

However, the Italian reality is far from a disaster and a failure. And the lessons to be learned are not (only) those stemming from (inevitable) mistakes.  The Italian experience offers several overarching intuitions that go beyond the current response to the pandemic and can be useful to inform discussions in other countries and help set future policies. The purpose of this piece is to shed light on some of these lessons hoping that they will not be forgotten once the pandemic is overcome.

Lesson 1: the healthcare system is the cornerstone of society

One of the most striking facts that has emerged in the current crisis is the fundamental importance of health and healthcare systems in society. The ancient Roman adage “health is the greatest wealth” has never been so pertinent.

No matter how obvious it may be to the general public, putting population health and healthcare systems at the core of government actions cannot be taken for granted. As a matter of fact, in every country the amount of resources spent on health and healthcare is a result of complex interactions between a range of institutional, social and economic factors, as well as political and cultural values.

Cost containment pressures and austerity measures adopted in recent years have had a significant impact on the amount of resources available for the Italian healthcare system. At present, Italy spends less on healthcare than most other western European nations.  Following the economic crisis in 2009, health spending per capita fell significantly until 2013, after which it started to increase but only moderately, and at €3,428 per capita, remains well below Germany’s €5,986 per capita. In line with the trend observed in almost all EU countries, between 2000 and 2017 the number of hospital beds per capita in Italy decreased by about 30% to 3.2 beds per 1 000 inhabitants, again, well below the EU average. The number of physicians, nurses and other healthcare professionals significantly decreased by more than 40 000 units in the same period. It has been argued that underfunding of the Italian health service might have made the current crisis worse. After years of strict financial control, many hospitals were operating at 95% capacity when the tsunami arrived. Faced with limited funds and strained capacity, the healthcare system had to rely on its core resource: people. Healthcare professionals at all levels, together with an extraordinary army of volunteers entered the battle without hesitation in the name of values at the core of Italian health service: universalism, equity and solidarity.

What are the lessons to be learned? First, by acknowledging the central importance of the healthcare system in society, the cost-containment policies of the last few decades that have been waged on healthcare systems around the world need to be reconsidered. Warnings of the risks of such policies have been neglected for too long. The current epidemic has demonstrated that debilitated healthcare systems can be brought to the brink of collapse with unforeseen consequences for the entire society. One country should not have to choose between public health and the economy: there is no such choice.  Let’s hope this principle will guide the allocation of the extra 3,5 billion Euro allotted by the Government to the SSN.

Second, the Italian experience with the pandemic has laid bare another undeniable fact, which often seems absent from many models for economic growth. All economic and social institutions fully depend on the activities performed by people. The pandemic exposed the fundamental relationship between the human component, production and technology. As more and more people were quarantined, activity slowly ground to a halt, sector after sector.  Without people, or better to say, without healthy people, society and the economy cannot work.

This is especially evident in countries where economies are particularly labor intensive and export oriented, like many Italian companies based in Lombardy, Veneto, Emilia Romagna and Piedmont, the regions most affected by the infections. In these areas export companies are largely micro companies  where people travel frequently for business. The Italian National healthcare system (SSN), and the recently appointed expert group for the kick-off of Phase 2, will need to address the risks to personal and public health from this type of economic model in order to react in a timely manner should another threat of a global epidemic arise.

Lesson 2: Clear stewardship is essential, especially in decentralized systems

The SSN is a highly decentralized, region-based system. The regional health authorities are charged with – among other duties - allocating the healthcare budget (equivalent to almost 80% of the total regional budgets), determining the number and type (e.g., public vs. private) of providers entitled to deliver healthcare services, regulating the remuneration system for hospital and community services and the co-payment schemes for resident populations.. The high level of autonomy granted to the regions is designed to i) respond effectively to residents’ health needs given different (socio-economic, demographic, geographical) contexts and to ii) make them accountable for their performance in achieving general, nationally-set, objectives in terms of quantity and quality of services to be guaranteed to all citizens.

In times of public health emergency, the effectiveness of decentralized systems can be measured by the promptness and determination of the coordinator (i.e., the central government) in creating the conditions to face the emergency (e.g., infrastructure, supply, evidence, communication) and by the local actors to efficiently enact, and if necessary to adapt, national guidelines for local execution, in a typical command-and-control manner. But COVID-19 has threatened this equilibrium. Since the beginning, some regions have charged that the central government’s response has been too slow and disjointed and have started organizing the response to coronavirus autonomously. This is still happening. Different regions are using different serological tests, adopting different measures to re-open manufacturing companies and economic activities or to curb measures to contain the spread of the virus. Why has this happened?

The central government has delivered a high-quality, low cost SSN with, however, huge differences across regions in terms of health outcomes and managerial capabilities, mostly in favor of the northern regions. Trust in central government has diminished. The northern regions see the central government as too tied to bureaucratic procedures to efficiently keep up with current and future challenges of the healthcare sector and have therefore learned to act alone. The southern regions see the central government as having deprived them of the capacity to rise again, victims, as it were, of austerity measures that perpetuate misery. The Coronavirus epidemic has underscored these differences since times of crisis tend to highlight – or exacerbate –inherent weaknesses.

What’s the lesson to be learned? The SSN is among the few healthcare systems that guarantees universal access to care to all citizens with no restrictions. Its performance is among the highest and its costs among the lowest. The SSN boasts excellent scientists and passionate practitioners who – whenever necessary – keep demonstrating an ability to give their best and close ranks. The SSN is one of the Italian jewels we are proud of and must protect. However, its future is endangered should the powers between the central government and the regions not be rebalanced.

The central government must become less bureaucratic, streamline processes and procedures, increase its capability to analyze and interpret future (demographic, epidemiologic, technological) trends so as to anticipate health policies aimed at preserving the founding principles of the SSN while keeping it financially sustainable. The central government should centralize those activities that have nation-wide implications and are not affected by local contexts, such as information system development, health technology assessment, coverage and reimbursement policies, in order to free regional resources that must instead be allocated to programming, designing and organizing the effective and efficient delivery of healthcare services to the local population. The central government should also incentivize regions to increase – and render equal - managerial capabilities across the country and between regions as well as between regions and the government. Stronger regional institutions, compared to the central government, tend to drift apart from the center if they think they have nothing to learn or gain. Weaker regional institutions drift apart from the center if they fear being blamed. We must not forget this when the coronavirus pandemic is behind us.

Lesson 3: Rethinking community heath

In a recent article, Pisanu, Sadun and Zanini said that “Italy followed the spread of the virus rather than prevented it”. That is true. Why has it happened, and could we have done it differently?

Although the Italian SSN found itself understaffed and underequipped when the COVID-19 outbreak started spreading so violently, it must be recognized that it would not be easy for any country to be prepared for such a tsunami. In a matter of days, elective surgeries were cancelled, semi-elective procedures postponed, and operating rooms turned into makeshift ICUs. With all beds occupied, corridors and administrative areas were lined with patients, some of them receiving noninvasive ventilation. In Italy there were approximately 5 200 beds in intensive care units when COVID-19 spread.  By March 24^th, another 3000 beds had been added, occupied by patients with SARS-CoV-2 infection. All in all, Italy tried to catch up with the spread of the virus by using and expanding hospital resources. The problem was that in many cases hospitals were the locus of infections themselves, thus adding fuel to the fire. But with differences across regions. Why?

This difference can be attributed (perhaps not exclusively) to two general reasons.  The first is linked to differences in the organization of primary care and the means of coordination between primary and specialist care.  Regions with more robust models of primary care have been able to keep patients at home by organizing different forms of remote monitoring, thus alleviating the pressure on hospitals and, at the same time, providing effective care to home-based patients. The second important reason is related to differing public health models, which in Italy are embodied by Local Health Authorities (LHAs) within specific regional departments. Over time, public health services have become disconnected from the gamut of services provided at the single patient level, reducing the level of coordination. Epidemics, as COVID-19 has reminded us, require that community interventions be coordinated with primary care. The case of the first patient intercepted in Codogno (a town just south of Milan in Lombardy) is emblematic: the patient was identified in the E.R. of the local hospital when his clinical profile gave pause to the staff, who overrode protocol and tested him for the virus.  Instruments centered on the single patient risk being overlooked, like a drop in the ocean, while community interventions (which failed not only in Italy, but elsewhere) are tailored to address the potential target, initiating sentinel instruments for groups most at risk and, most importantly, moving outside the hospital incubator. To move toward community intervention requires reconnecting the public health and hygiene mandate with that aimed at guaranteeing individual patient services through large scale managerial action.

Lesson 4: Boosting management capabilities to a new level

If the central government (perhaps inevitably) has been slow to react, the individual regions, and more particularly, LHAs, hospitals and more in general healthcare providers, have shown great initiative in finding operational solutions. Hospitals were able to transform their organization and facilities with a rapidity never seen before, where major limitations have been the availability of resources (e.g., protective gear, ventilators, oxygen, test kits) and clearly not the willingness of medical and non-medical personnel to experiment with novel solutions to respond to the emergency. We have seen hospital facilities and equipment completely transformed and expanded compared to the number of intensive care beds available in the past.

If there is one thing that Italians have realized, it is that LHA and hospital systems can be both flexible and controlled, thanks in large part to the ability of top management to improvise within a system full of constraints and in unknown territory. This silent community of professionals (healthcare managers, starting with the general managers) acted by reorienting the organization of LHAs that had become unwieldy (the average population covered by an LHA has climbed to 500,000 inhabitants) due to continued mergers and concentration of processes over the last few years. The hospitals and LHAs were able not only to withstand the onslaught of the virus but also weather the uneasy relationships between the national, regional and local levels.

However, if it is true that in several cases LHA and hospital top management gave their best and exploited their management capabilities to fight the emergency, it is also true that this did not happen evenly across and within regions. Now, at the starting of “Phase 2”, new questions arise. For instance, what should be done with this newly expanded capacity once the Covid-19 epidemic becomes (as we hope) only a bad memory? Certainly, a large area should be found that could accommodate this new capacity, one that could be quickly activated should a new wave of infection come about or a new threat emerge. Certainly, we need to rethink the diagnostic platforms that limited the possibility to test large numbers of people to be able to capture the target population of the virus. Some areas responded to the pandemic by reorganizing service delivery, where new models of care emerged such as networks or hub-and-spoke, even constructing new hospitals dedicated solely to COVID-19 patients. How should these new models and facilities be employed, now and in the future? These questions need coordinated answers, inspired by clear vision and strategy, and not excellent, yet isolated, solutions.

Until the SSN is able to incentivize, maximize and coordinate knowledge sharing between providers and between regions, its performance will continue to be supported by the ceaseless work of SSN individuals. To win the championship we need a strong, coordinated team and not individual goal scorers.

Per Aspera Ad Astra

Coronavirus brought half the planet to its knees. When it will be over, human losses will be painfully countless while economic downturns have already started counting thousands of billions of US dollars worldwide. As strange as it may seem to say, we believe that Covid-19 did not create new problems but violently brought to the surface many of the challenges healthcare systems have been facing for a long time. We are paying a very high price for this reminder.  When this tragedy will be over, the worst mistake we could make is to forget, driven by the eager and legitimate wish to regain our normal lives. But this would mean that all the pain has led to nothing and has served no one. An evil we do not want and cannot afford.

When COVID-19 will pass, the lesson to be learned is that health cannot be exchanged in the market since this leads to inefficiencies and inequalities that – in one way or another – need to be more than compensated for by other productive sectors of the economy. Governments play a pivotal role in ruling healthcare systems, and this becomes even truer in times of epidemics, i.e., whenever health clearly reveals its ‘public good’ nature. Entrusting healthcare production and delivery to the market is an illusion that abruptly turns into a delusion.

Healthcare is the cornerstone of society and must be funded appropriately. Technological advancement, modern capital equipment, skilled health professionals, all contribute to improve population health, and adequate resources must be allocated according to a cost-effectiveness principle. Investments in management capabilities – with adequate compensation - are fundamental to shape and steer healthcare systems’ organizations where, today-unimaginable, scientific progress is relentlessly bringing us. Health and education are among the most important determinants of wealth and need to be deservedly rewarded. Miracles cannot last forever.

Translated by Giuseppe Barile.