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3.
The National Health Service reformation. Turning into a business
By the means of the
act nr. 111 on April 4th 1991 that turned the legislative decree n.
35 on February 6th 1991 into law, it was
enforced the transition to a new system: in order to limit the role
of politics, the Management Committee was replaced by the Busters Committee
(abolished on 2/3/1993 passing the corresponding functions to Majors
or to the Majors' Conference) that sided the management activity, which
in fact taken away to the local bodies, of an extraordinary administrator.
It concerns an advance of the managerial approach by the means of the
establishment of a monocratic organ, inaugurated definitively throughout
the figure of the general manager contemplated by the legislative decree
n.502 on December 3rd 1992.
The reformation, passed
by the legislative decree n. 502/92 (and following alterations), aimed
to correspond to those economic characters and devolvement of responsibility
requirements of the entire involved bodies (Regions, health structures,
citizens) emerged from the failing actuation of the 833/78 act. The
main targets of the new reformation are:
- to balance the services
performance all over the territory, by defining uniform assistance levels;
- to attribute greater power and responsibility to regions;
- to give citizens
full freedom in selecting between public and private structures;
- to separate, by marking
the limits, the political role from the managerial one: - to involve
the medical class in the economic management of services; - to turn
into autonomous and liable the health structures; - to finance the health
activity basing on the effectively performed services; - to put in competence
the several structures, both public and private.
The main novelty of
the decree is the establishment of a Local Health Units organization
model different at all by the juridical, organization and territorial
viewpoint.
The Local Health Unit
becomes indeed a public personality enterprise, featured by organization,
patrimony, accounting, managerial and technique " (502/92 art. 3, c.
1, legislative decree, modified by the legislative decree n.117/93),
and therefore, as regard to the parliamentary delegation act n. 421/92,
it is cancelled the definition of "Region's instrumental body ").
This way it is configured
a body really autonomous from municipalities, or mountain areas municipalities
associations or Regions, giving more chances to manage unboundedly from
the political events of the local bodies. The high skilled hospitals
turn themselves into Hospital enterprises; the other ones will go on
their activities as facilities of the Local Health Units, even if they
have economic- financial autonomy.
The apply for a private
enterprise model to give to the health structure lays on the need to
employ efficiently the scarce country's resources, by not introducing
a real market system - that would be in open contradiction with the
solidarity principle over which the National Health Service lays - but
'simulating', we could say, the private management inside a model that
keeps on being "public".
A clear market mechanism
introduced into the public system concerns the financing modalities:
once confirmed the citizens' freedom in selecting the health structure
that most corresponds their needs, the law establishes that the performance
toward enterprises and health facilities will base over the carried
out services. While in the previous system the production costs determined
the financing amount, the 502/92 legislative decree upsets the standpoint
by introducing the competition principle: the citizen-user by benefiting
from a service, even if he does not pay directly (except the minimum
quota of the co-payment) determines the 'purchase' of the service, that
means the chance to cover costs. Such costs, on the other side, are
defined by Regions on the base of national level criteria, in order
to have unit fees within which the enterprise must keep in order to
not increase uncontrollably the expenditure. It involves a thorough
ascertainment of both services any enterprise can offer to correspond
to citizens' services demand and the cost related to each service.
Regions' financing
to the single health structures lays over a systematic analysis of costs
(legislative decree 502/92, art. 4, c. 7). (5)
The health programming
is bounded in order to not exceed the financial resources put on disposal
by the national financing law.
The case the Regions
would want to finance health services exceeding the assigned quota,
they must apply for alternative forms of financing, by subtracting funds
from other regional balance items or by imposing an increase in tax
to citizens.
The region programming
action must be developed in an efficacious way in order to supply a
health service that on a side must keep the costs defined in the budget,
and on the other side, must not lower the services level by both the
qualitative and quantitative viewpoint.
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