Ettore Jorio
A Changing Welfare
Our country’s Health
System has recently gone through a number of structural1 proposals, which
have deeply affected its organisation and operation, and therefore, in many
ways, distorted the original basic principles of the National Health System,
which were of a typically publicist nature.
All the changes which have taken place – some of which may be viewed as revolutionary
owing to the introduction of principles of a strongly privatistic2 nature
– should in any case be viewed within the broad reforming debate, which has
universally began, on the plan to reorganise the Welfare system; this debate
is involving the entire western Society and every level representing civilised
society. Today’s Civil State, which has reached its present standards thanks
to the many battles it has had to fight on the whole for the achievement of
civil rights, has attained major achievements and reached significant goals
in the protection of basic human and personal rights. In its attempt to grant
all citizens “basic levels of income, assistance and service”, it has however
generated an exponential and uncontrollable growth in the public deficit.
In all the Western countries, this Welfare State has proved to be exceedingly
expensive and inflexible in its twisted bureaucratic mechanisms, which have
made it increasingly slow and inadequate, and for this very reason extremely
exposed to phenomena of shameless corruption at all levels.
Therefore, the urgent need to reduce the public deficit that has built up
over the years (the threshold set by the Maastricht treaty for the European
Union Member States was 3% of GDP) has significantly influenced the domestic
political choices made during the ‘80s and ‘90s. Such choices, which were
aimed at controlling public expenditure through the spending cuts policy,
have assigned to the private sector, which has been deemed more “entrepreneurial”
than the Public sector (and we ought to add: it would have been a real disaster
had the public sector been more entrepreneurial than the private one!), the
management of large sectors of the economic world. All this has endangered
the guarantees acquired by the needy individuals of our civilised society
and resulted in a failure to guarantee respect for the principle of solidarity3
towards the weaker classes, which are increasingly easy to identify in metropolitan
circuits, in the name of the establishment of a liberal state founded on “risk”
rather than on “guarantees”.4 The need to provide for a radical reform of
Welfare, and the associated need to redefine the minimum assistance levels
to be guaranteed to everybody, is before the eyes of us all. Not easy: the
political enterprise, the formulation of proposals, the courses and decisions;
it is almost impossible to attain people’s consensus at each level on the
choices made and on the changes possibly introduced! These are all issues
which disturb and will continue to disturb in the course of the reforms those
who play a leading role in politics and the representatives of the social
parties, respectively required to propose and share, and expected to “orchestrate”,
the hypothetical changes to be introduced in the Welfare State. One thing
we are sure about: the reform must be done! But it certainly cannot provide
for waiving fundamental rights that have been acquired, even though it will
have to radically review the system based on the typically welfarist logic
of a “wet-nursing” State from the cradle to the grave: that is a State that
has so far guaranteed, and continues to guarantee, inefficient and ineffective
interventions and which, in doing so, continues to endanger the possibility
of guaranteeing in future social rights and, the associated fulfilment of
the “basic” and social security needs.
As regards the debate on Healthcare, a right which is certainly indisputable
and therefore indissolubly linked to the principles of equality and freedom5
, as acknowledged by article 32 of the Constitution, it ought to be pointed
out that no organised system in the world, whether it be liberalist or universalist,
has succeeded in supplying a tangible response capable of blending ethical
and economic principles. The political debate is increasingly concentrated
and focused on this challenge. By now, it has abandoned inflexible and preconceived
ideological positions, which are unable to supply comprehensive solutions
to meet the continuous requests coming from the civilised society. In this
way, this debate has ended by identifying points of view that, even though
differing substantially, are all aimed at a definite and significant reorganisation
of the Welfare State, with the aim of guiding it towards “equality of opportunities
and not equality of results”.6 This orientation is meant to ensure all citizens
are granted a minimum level of assistance and, at the same time, to stimulate
individual and collective responsibility, thus interrupting the type of policy
pursued so far by all governments and excessively focussed on the support
of civil rights. Italy, in particular, has chosen to stand by a principle
of “social solidarity”. In this regard, it has felt the duty to answer for
the fulfilment of certain Healthcare requirements through the public system,
whilst at the same time introducing rules “deemed necessary to increase the
level of efficiency in the employment of resources and in the assumption of
responsibilities by the various parties with respect to the result-resource
ratio”.7 The 1992 Healthcare reform, defined and for certain aspects rewritten
with the 1999 rationalisation provision (the so-called Bindi Decree), has
changed the Local Health Units into enterprises, by introducing more strict
managerial principles, typical of private firms, within a system that continues
to be public, in compliance with and as a safeguard of the irremissible universalistic
principle. Therefore, the Italian reformistic policy appears to be aware of
the fact that the definition of a new Healthcare model cannot only take into
account expense control issues and therefore only operate in terms of “management
financial rationalisations”8 , also with the risk of prejudicing a right that
has already been acquired (and therefore consolidated) by the individual who
exercises it, but must above all intervene to correct those operating “anomalies”
which most times are generated by both parties to the Healthcare transaction:
the party who manages the ‘supply’ and the party who represents the ‘demand’
and avails itself of the service. The debate that has so far preceded and
accompanied the reforms in their various stages concerns, in fact, the substantial
aspects of competence and of responsibility. On such aspects, the State finds
itself in a strongly competitive system, as far as social solidarity and Welfare
themes are concerned; this happens because the related responsibilities are
claimed by the Regional Authorities, which are more determined to acquire
an ever increasing and more autonomous role in exercising the legislative,
administrative and financial power, which had so far been held and exercised
almost exclusively by the central authority. This trend is shared by both
Italian and European politics, where national States - in order to face the
rapid increase of the public deficits through are more effective and incisive
control over Healthcare expenditure – relieve the national balance from the
responsibility of having to form and represent “the primary means to finance
social security”9 , by delegating to lower government levels the responsibility
of raising funds with which to implement national policies relating to Healthcare.
In Europe
The reformistic surge that has affected Europe during the ‘90s has substantially promoted “first of all a reconciliation between the State and the market, between public centralised controls and increased decentralizations, mutualities and users’ freedom of choice (especially for users who have money to spend)”.10
Great
Britain is the country which first paved the way for Welfare, through
the introduction of a healthcare system “financed through public taxation
with a universalistic destination”.11
The reform approved in 1991 provided for, and established, a sharper decentralisation,
but above all the introduction of market or like-market procedures, by drawing
a distinction between “public buyers” on behalf of consumers (providers) and
“credited” suppliers, both public and private (producers); between these parties
a purchase contract was drawn up for goods or services designed for people’s
health, in strict compliance with cost-effectiveness and cost-efficiency (cost-usefulness)
criteria.12 The 1999 Labour reform, whilst preserving a distinction between
buyers and producers, in fact took a step backward. It abolished competition
among suppliers to avoid the prevalence of a rigid market system, which risked
to focus on expense control rather than on the quality of service. As to decentralisation,
the 1991 reform had left the chief planning and orientation authority at a
centralised level, delegating to “peripheral” authorities only the responsibility
for results, without transferring to such any decision-making power.
The 1999 Blair reform, on the other hand, provided for a more active involvement
of local authorities in the planning stage, thus ruling out any centralised
intervention in the employment of resources, the latter being handled autonomously
and with direct responsibility by the suppliers of services, named “Primary
Care Groups”, which guarantee the management of basic healthcare assistance,
and “Primary Care Trusts”, which on the other hand are companies supplying
services.13
France
started its reforming programme in the Healthcare sector in the early ‘90s.
With the law no. n. 91-748, dated 31 July 1991, which was immediately amended
with the law no. 91-1406 of the same year, the incumbent Government had already
attempted to introduce certain legislative tools aimed above all at preventing
the damage resulting from excessive Healthcare centralisation and, hence,
at depriving Hospitals of their exaggerated leading role, self-acknowledged
during the historical process of supplying Healthcare services, by assigning
to territorial facilities a more specific role. Through the approval of a
number of laws14 , over the 1995/97 period, the Juppé government attempted
to make up for the immoderate growth in public spending in the area of social
security. Such laws introduced specific measures that, on one side tend to
increase central political control over healthcare expenditure and, on the
other side, to increase, through a decentralising process, the transfer of
competence from the large health insurance schemes and hospitals.15 Interesting
novelties were also introduced by the “ordonnances” no. 96-344 and 96-346
of 24 April 1996 as regards the reorganisation of the healthcare system and
of the public hospital system, as well as the introduction with full rights
of crediting. This establishment was identified by the French legislator as
an indispensable juridical tool for the financial and functional survival
of “health enterprises”16 and, at the same time, a tool which might guarantee
high quality conditions and results in the production and supply of healthcare
services. This establishment, even though not comparable to a juridical deed,
in that it does not involve direct juridical effects, attracts everywhere
great interest by the doctrine. It is defined by the French law and shared
by the careful transalpine juridical and administrative school: “L’accréditation
est une procédure d’évaluation externe à un établissement de santé, effectuée
par des professionnels, indépendante de l’établissement et de ses organismes
de tutelle, concernant l’ensemble de son fonctionnement e de ses pratiques.
Elle vise à s’assurer que les conditions de sécurité et de qualité des soins
et de la prise en charge du patient sont réunies ”.
Germany17 has the most dated healthcare system in Europe and, because of this, displays the most traditional institutional structure. The State governs the system “from above”, in that it simply dictates the rules within which the operators are to then carry out their peculiar institutional roles.18 Therefore, the central power is not invested with any responsibility in the search for financial resources, let alone be identified as the “juridical” owner of the enterprises producing healthcare services: therefore it is not directly responsible for the Healthcare “supply”. Indeed, the system is entirely based on compulsory social security funds, which are largely available on the country’s territory. It operates according to a regional scheme, of a federalist nature, although with the presence of numerous (maybe too many!) institutional parties (the Länder, the social security funds, the hospital service producers, the panel doctors, the social sector). Such parties generate too often conflicting situations among each other, also in ideological terms: these conflicts, which are often difficult to overcome, in view of their equal role in the decision-making process and in view of the absence of an institutionalised co-ordination, result in a slower system. The German system has so far been the “health system” which in Europe has had available the greatest financial resources, also thanks to the fact that over the latest years it has produced the highest per capita income. Today, with the first difficulties arising in the economical situation, some serious operating problems have started to emerge within the entrepreneurial facilities that are to supply the services, which are experiencing more serious difficulties than expected in accepting the logic of assumption of responsibilities and management commitment. Besides, the current system organisation does not facilitate the unitariness of the intervention, owing to an inflexible impersonation of the various roles by the institutional parties involved, that are possibly too busy carrying out their “prevalently” financial institutional tasks.19 Holland realised, as early as in 1987, a Healthcare organisation that acknowledges the value of the mixed public-private management. This mix has produced on one side a strengthening of the Government control and equalisation role, whilst on the other side it has emphasised the freedom of users, who are not covered by a public health insurance, to choose an “additional” private security scheme, to be compulsorily born at one’s own expenses. The needy are however granted full healthcare assistance, whose cost are entirely borne by the State. Such a model, which is regarded as alternative to the English one, (which has for a long time been regarded as the model which everybody should refer to!), is meeting with significant success and winning general approval, especially in Italy (the Lombardy regional authority in particular explicitly refers to it also in its own provisions!). We feel this popularity has been deserved, for having successfully achieved a harmonisation, in a gradual but determined manner, between the national health system on one side and private (non profit) health assistance and private (profit) health insurance on the other. The conceiving of this system first and its orderly implementation later, have made it possible to achieve the desired expenditure control, without however diminishing the level of performance in terms of quality and quantity.20
Sweden’s experience of the reform has directed the system changing process towards the “improvement of an organisation model which, at a territorial level reports to regional authorities, by transforming the counties, which used to be administrative decentralised centres, into decision–making decentralised centres”.21 The course of the reform is however slowed down by the ideological contradiction emerging between wanting to maintain a rigorously public and universalistic system and, at the same time, having to implement the reform of the system itself according to merely entrepreneurial principles. Despite such difficulties, the reformation process is making progress and hence drawing a sharp distinction between the responsibility for financing interventions, entrusted to the purchasing units, and the responsibility for the management of facilities that may guarantee the supply of services and have the necessary autonomy; these are facilities towards which, of course, the user benefits from “free choice”. The Swedish model appears interesting as a whole, but above all because of the leading institutional role entrusted, in the process of reorganising the Healthcare system, to the most decentralised administration levels: the counties, which have been put in charge of expenditure control and of the rationalisation of the social and healthcare supply.22
Spain23 has recently gone through its reformistic stage in ways which, in certain respects, are very similar to the Italian experience, owing to the choices made in favour of the assignment of the rationalisation and managerialisation24 of Healthcare to the so-called “autonomous communities”, in which the country’s territory is divided. This decentralisation process is not however the same on the whole national territory, in that only “seven”25 (out of the seventeen) autonomous communities (in which 62% of total inhabitants lives) have planning, organisation and management power with respect to the Healthcare system. The remaining ten, on the other hand, are only in charge of local planning responsibilities, whilst the management and financial aspects are handled at a central authority level. The significant level of autonomy granted to certain communities (such as Catalonia) has made it possible for these to accelerate the reformistic process within their own territory, thus also forestalling the central government in the implementation of the managerialisation process and hence the so so-called “administrated competition”.26 The political choices made by the Spanish government with respect to Healthcare have thus allowed the emergence – although within a common course leading to the full assumption of responsibilities by intermediate administrative levels, as regards the retrieval of resources and management – of substantial differences and therefore non-homogeneous results throughout the territory. Such differences have created much discrimination among the people, which have been the cause of conflictual relations between State and Regional authorities and among the Regional authorities themselves. These conflicts have been so exasperated that only a further stage of the reform will be able to handle the task of overcoming them!27 Belgium is experiencing since 199528 a continuous legislative evolution with regards to Healthcare; this legislative course started two years after the completion of the rules and regulations establishing the Federal State, in 1993. During the previous decade the central and peripheral legislator have pursued specific objectives in terms of Healthcare29 reorganisation (e.g.: reduction in the hospital healthcare supply with the contemporary identification and creation of alternative services to hospitalisation). Therefore the legislative deeds adopted were strongly innovatory in contents, and were meant to radically act on the pre-existing scheme through reforms of a structural and management type. As to the latter objective, a significant change in the financing system was introduced, by adopting budget methodologies for each activity and creating specifically designed facilities aimed at co-ordinating the interaction of the various parties within the management of the whole social and healthcare sector. As to legislative competence, it is the Federal State that is to set forth the general principles of the healthcare policy and set the basic criteria and rules for planning, as well as those relating to management, infrastructure financing and destination of surplus, or coverage of public hospital deficits. The latest legislative activity, as well as the outcome of the challenge which has arisen between the public and private hospital systems, will have to overcome the financial difficulties and make a final choice between two juridical alternatives. As to the latter, the parties involved have reopened the question relating to both the regulation of the whole system and the institutional set-up; this revision process has been solicited by the social and welfare requirements politically expressed by the “linguistic differences” and by the historic competition between the private and public hospital system, the latter having always been in a minority position compared to the former.
Hungary offers one of the most interesting examples of countries which, even though having a socialist culture and system background, is making great efforts to adjust its rules and its economy to those which are typically western, with the main purpose of ensuring and quickening its deserved entry into the European Union and be hence able to face in a more complex manner the challenge represented by the globalisation of the market. With respect to Healthcare, the Hungarian reforming process started in 1990 and has gradually continued till today; however it has gone through delays and indecision situations, possibly caused by the cultural background, both among political leaders and the citizens/users, which is what makes it difficult for Eastern countries to accomplish the “capitalist” shift of the social and welfare system. The present Hungarian healthcare system30 is based on social insurance; this is an independent insurance compulsory for everybody. The costs involved by the service are therefore largely borne by the users through contributions paid, and allocated to the institutional operators who are in charge of investments, identified by the legislator, and to the National Fund, which finances the operating expenses. The organisation of Hungarian Healthcare is based on a public management entrusted to the State and to local authorities. Both unconsciously contribute, with their old bureaucratic rules and with their “habits”, which are not in line with the new requirements of the citizens, to the inefficiency of the service and to the inefficiency of great part of their performance. Healthcare services are granted to the users by local public institutions, by private autonomous subjects and by “credited” private facilities, the latter having only recently been introduced into the system. Spurred by the new Healthcare demand, promoted by a greater sensitivity by toady’s political leaders, who are responsible for ensuring the entry of this important country into Europe, the new system rules are going through an advanced reform process. A process that will undoubtedly be codified, thus establishing in Hungary that “healthy competition” between the public and private sectors, also in the management of people’s health.
Overseas
Countries
Certain extra-UE experiences are worthy of being analysed at this stage, although
in a rather concise manner, whilst we postpone to further works (which we
mean to accomplish) a more careful comparison between the European systems
that have just been outlined and those applying to overseas countries, which
we shall now refer to. The experiences we shall now report relate to three
major countries: Canada, Brazil and New Zealand. We have identified these
for three different sets of reasons:
- Canada, because it has always represented for our country a model of public
organisation to refer to;
- Brazil, in that it does since ever represent for our country a model of
public organisation to refer to (but it represents a country where medical
staff benefits from an excellent professional training!).
- New Zealand, in that it represents a model healthcare system to be imitated
in terms of efficiency and effectiveness. Canada, ever since the late ‘40s,
had entrusted the provinces with the task of implementing the Healthcare system
reform projects. In the ‘60s, it decided to adopt, as a national model, the
one implemented in the Saskatchewan province and to contemporarily involve
the federal government in the financing of provincial healthcare systems,
whose maintenance costs had been gradually increasing. Throughout the ‘80s
and ‘90s a conflict between the central power and the autonomous provinces
gradually developed.
The reasons for the institutional conflict (which still exist today) may be
summarised as follows:
-The federal government expects the provincial authorities to comply with
the universalistic principles31 of the healthcare system, based on which each
citizen, irrespective of the territory he/she belongs to, has the possibility
of benefiting of healthcare services with the same type of insurance coverage;
-The government tends to cut down on the funds transferred to the provincial
authorities; -The provincial authorities, being directly responsible for the
management and organisation of their Healthcare systems, feel entitled not
to comply with the national regulations, since they do not have the necessary
financial coverage, and therefore tend to supply differential services in
favour of their citizens. Hence a challenge towards the central government
in search of the solution: “how to combine (reconcile) in future years tax
decentralisation with political centralisation, that is, how to get national
rules for social programmes to be complied with, whilst at the same time reducing
the financial contributions to such programmes”.32 The system selected by
nine of the ten Canadian provinces, for an improved operation of their healthcare
systems, is management rationalisation. Each province has however adopted,
within the limits set by the central government, a structural organisation
of its own, whereto entrust the efficiency and cost-effectiveness of its Healthcare
services. Among the various existing models, we hereby wish to identify two,
which somehow also represent the others: the three-level model and the two-level
model. Stating beforehand that in both “organised systems” the chief responsibilities,
that is the first-level ones, which in fact relate to system management, are
assigned to the Provincial Healthcare Ministry, it is hereby worthwhile mentioning
the other levels of the two selected typologies: -in the three-level method,
two further facilities are identified to complete the organisation circuit:
a regional level and a local community level.
Therefore a system having a pyramid-shaped structure, with the Ministry at
the summit, the regional facilities as an intermediate stage, down to the
local levels, which are also provided with an administration, but often have
merely advisory functions. According to this typology, the regional government
is responsible for the distribution of resources, co-ordination of services,
analysis of needs and evaluation of results. The provinces which have adopted
this model are: Alberta, Nova Scotia and Manitoba; -in the two-level method,
on the other hand, the only level left beneath the provincial ministerial
one is the regional level, and therefore, unlike the three-level method, it
lacks a local-level management facility. The provinces that have adopted this
model are: the above-mentioned Saskatchewan, New Brunswick and Prince-Edward-Island.
The remaining four provinces (Ontario, Québec, Newfoundland and British Columbia)
have adopted “tailored” regional healthcare management models, in order for
each one to satisfy its own requirements33 .
Brazil expresses in Healthcare supply one of
the most significant contradictions of its way of being a State. Whilst offering
a rather inefficient social and healthcare assistance, Brazil displays an
extremely high-quality supply of medical-healthcare operators, so high that
it represents an international point of reference for medical training in
certain specific fields (e.g.: aesthetic surgery). In Brazil the reforming
course started in 198734 , with the establishment of Local Healthcare Systems,
the so-called Silos. With this reforming measure, the healthcare decentralisation
process gradually started taking shape, with the establishment of “healthcare
districts”, which represented the organisational and operating basis of Healthcare
supply on the territory. With such rules, legislators attempted to unify,
under a centralised managerial control, the responsibility for healthcare
intervention, which appeared to be disorganised, and therefore scattered over
different decision-making and government levels (Federal Government, States,
Municipalities). In 1988, in re-writing the new Constitution, the first-rank
legislator introduced the Unique Healthcare System (SUS) together with a few
major principles: universality of assistance, social and healthcare integration,
the priority of prevention, people’s participation, management decentralisation
and hence great power to Municipalities in the management of local healthcare
services. Following this stage, great changes have taken place in Brazil,
especially as a result of a more active participation of the parties playing
an institutionalised role (citizens involved in decision-making, health operators
requesting extra training, etc.); such changes have renovated the healthcare
concept and stimulated a demand, which is ever more pressing for service quality
and, therefore, a stimulus for public supply, which is forced to compete with
the private supply to satisfy the legitimate demand that people strongly express.
The serious problem that puts SUS in a difficult position is the same problem
that has always troubled Brazil, that is a strictly financial one. The current
political strategy tends to “hierarchize” assistance, against the correct
principle according to which it should be “generalised”, so only minimal assistance
will be granted to everyone and the dramatic result will be a drop in the
quality level of the Healthcare status for most of the population of this
large (but poor!) South American country.
New
Zealand formulated its first healthcare system by adopting the
institutional and organisational features of the English system: a system
ensuring universality of assistance and therefore granting the whole population
free access to the services; a system providing for the cost-financing of
the service to be entirely borne by the State and, lastly, excluding any direct
participation by the citizen to the expense of the requested service. During
the ’80s the system structure changed to a regional one, through the identification
of fourteen Regional Healthcare Committees35 made up of selected local “politicians”,
who were only subsequently provided with the assistance of other technical
members appointed by the government. Such local authorities were granted financing
by the Parliament, although these funds were in fact made up of “resources
which had an almost compulsory purpose”, in that they were scarcely sufficient
to guarantee the operation of existing hospital facilities. Between 1991 and
199336 the great reform took shape and finally came into force in July 1998.
With this reform, among the other things: -Some kind of common Fund was identified
and established; this was a pooling in which the system made the financial
resources required to finance first- and second- level healthcare assistance
converge; -Four regional Healthcare Agencies were established and given responsibility
for purchasing, and were financed through the system of the flat per capita
contribution; -The regional healthcare councils were “cancelled” and public
hospitals were transformed into twenty-three “Crown Healthcare Enterprises”37
, inspired by typically privatistic principles and remunerated on the basis
of the healthcare services rendered; -Each citizen was offered the opportunity
to choose, as an alternative to public assistance, a private health insurance
scheme with expenses in part born by the State; -Lastly, prescription charges
due by the users were significantly increased and, at the same time, reductions
were introduced for “poor” citizens and for patients affected by specific
pathologies. During the following years, some of these choices where corrected,
but some of these adjustments were implemented in practical terms without
the change being coded through a law. The most revealing, among such “adjustments”
is the one contained in a statement, or rather in a recommendation addressed
to the above-mentioned twenty-three “Crown Healthcare Enterprises”, which
were invited to be more “socially responsible” and therefore less “profit”
oriented; in other words to devote less care to the application of principles
of a typically privatistic- entrepreneurial nature and be closer to people’s
needs.
The Healthcare models analysed in this article are quite different from each
other: indeed, to restrict our analysis to Europe, we have a chiefly public
National Health Service in Great Britain, Spain and Sweden, a Health Insurance
model in Germany, France and Belgium, and the Dutch model, characterised by
a marked deregulation, associating social and private insurance coverages,
with a prevalence of private suppliers, who are however subject to a very
careful review by the public. Such models have followed, through different
manners and timings, two basic guidelines:
a) the separation between demand-related responsibilities, which can be entrusted
to national health services, insurance coverages or regional and local authorities,
and supply-related responsibilities, represented by the traditional hospital
structures, within a system integrating public facilities and private (profit
and non-profit) facilities;
b) a greater level of decentralisation of demand-related responsibilities38
.
(traslation by Interpres)
(continua)
Ettore
Jorio
Professore di Diritto Sanitario
Università
della Calabria
