The Health Service Faces the Challenges of a Fragmented Society
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The Health Service Faces the Challenges of a Fragmented Society

THE 2018 OASI REPORT, PRESENTED TODAY AT BOCCONI, HIGHLIGHTS A STRONG CRITICALITY IN MEETING THE NEEDS OF THE ELDERLY LIVING ALONE. ONLY 32% OF THE NEED IS COVERED AND THERE IS ONLY ONE BED EVERY NINTH DEPENDENT PERSON

After having reached financial balance, managing to maintain the population in good health, the Italy’s health service (Servizio Sanitario Nazionale, SSN) must now resolve some territorial imbalances and take up the challenge imposed by the fragmentation of society, which creates new fragilities and new needs. This is stated in the Oasi Report 2018 an observatory on the Italian SSN, presented today at Bocconi by Cergas, the Centre for research on health and social care management.
 
In 2017, according to the Oasi Report edited by Francesco Longo and Alberto Ricci, the SSN recorded a slight accounting deficit (282 million euros, or 0.2% of current public health expenditure), with the regions of Central and Southern Italy now proving as virtuous as Northern ones. In the same year, SSN expenditure increased by 1.3% to 117.5 billion euros, bringing the average increase from 2012 to 2017 to 0.6% nominal per year, equivalent to a zero increase when inflation is taken into account.
 
Italian healthcare expenditure is 8.9% of GDP, compared to 9.8% in Great Britain, 11.1% in Germany and 17.1% in the United States, with the SSN covering 74% of it. In the last five years, the share of healthcare expenditure in total welfare expenditure has fallen from 22.8% to 21.8%.
 
The main indicator of a population's health, life expectancy, remains excellent (82.8 years in 2016), but is growing less than elsewhere, so much so that, from 2010 to 2016, Italy went from second to sixth place in the world in the World Health Organization's ranking of longevity. While mortality rates for all major diseases are declining, mortality due to mental disorders and diseases of the nervous system is increasing. The territorial differences are still quite marked: life expectancy in good health is 56.6 years in the South and 60.5 years in the North, with Calabria settling at 52 years and the autonomous province of Bolzano reaching 69. Until 2016, before the introduction of legislative restrictions, the territorial mobility of patients on the South-North route was also increasing.
 
What remains unfulfilled, however, is above all the demand resulting from social change, which leads to a progressive fragmentation: in 2017, 32% of families were single-member (8.1 million individuals, of which 4.4 million over 60) and the ratio between the over 65 and the active population, at 35%, is the highest in Europe. Between 2010 and 2017, the population over 65 increased by 1.3 million people (+11%). This increase is due to the ageing of the numerous demographic cohorts of baby boomers: a physiological and positive trend in itself, because it confirms the long life expectancy beyond 60 years. The imbalance between the population over 65 and the population of working age (which is decreasing due to the drastic drop in birth rates) is a cause for concern. In the next 20 years, in fact, the ratio between the over 65 and the active population will increase from 35% to 53%: more than one «old man» for every two people of active age.
 
This evolution creates and will create increasingly serious imbalances in the social and health services that today, according to the Observatory, only cover 32% of the need. Particularly critical is the availability of beds in health facilities for the dependent elderly, amounting in 2015 to about 302,000 against 2.8 million people in need. The system also struggles to ensure continuity of care for the elderly after hospitalization: one every fourth over 85 is hospitalized at least once a year, with an average stay of 11 days, but only 16% of these are discharged providing some form of continuity of care.
 
From an organizational point of view, the authors of the Observatory note, the conditions of the staff of the SSN are becoming increasingly critical. The blockage of turnover, which has been used for years as the main tool for reducing expenditure, is having an impact: 53% of doctors are over 55 years old and the number of candidates for medical specialties is more than double the number of contracts funded. “The problem is the scarcity of resources for hiring and training, not the lack of doctors», says Alberto Ricci. In administrative roles, the share of over 55 is 44% and between 2006 and 2016 the number of under 35 has decreased by 64%.  In Italy, the nursing staff is less than half that of Germany (5.6 nurses per thousand inhabitants, compared to 12.9) and the regions of the South always suffer the most: in 2016 Lombardy had 9.6 SSN employees per thousand inhabitants, Campania 7.3 and Lazio 7.1.
 
Despite the many critical issues, the Italian health sector is confirmed as a dynamic sector open to innovation, not only in the clinical field, but also on the managerial side. The 2018 Oasi Report dedicates several chapters to these dynamics of «karstic innovation», such as the enhancement of professional knowledge, the redesign of programming and control systems, the strengthening of operations management (patient logistics and production assets) and many other aspects. Obviously, there are also open questions. «In the context of financial and institutional stability, companies confirm their ability to activate new management tools and service models, but it is necessary to identify the strategic priorities towards which to direct innovation», concludes Francesco Longo.  «Moreover, the instantaneous times of political-media communication and the long implementation times on the administrative side are becoming more and more divided. The role of management remains that of identifying strategic priorities and taking care of their implementation, aware of the elements that determine their own spaces of autonomy».

by Fabio Todesco
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