Italy's Resilience Plan for Healthcare Is Falling Apart

Roberta Villa, MD


September 21, 2023

When Italy's National Recovery and Resilience Plan (NRRP), which was created using special funding made available by the European Union, was approved and presented to the public in 2021, there was an audible murmur of surprise coupled with a certain amount of ill feeling. Less than one tenth of the resources (just 8.2% to be precise) were intended for the healthcare system: the very system that showed the country its limits during the pandemic.

In absolute terms, however, it was a large sum of more than €15 billion, 7 billion of which should have been used to bolster Italy's healthcare system, including telemedicine and home care provision. A second portion of over €8 billion was to be used for indispensable and now urgent digitization projects and innovation of the healthcare system, alongside investment in research.

The reform envisaged the creation of 1430 community units that would allow citizens easy access to primary care services provided by general practitioners, primary care pediatricians, and an integrated multidisciplinary team to handle visitors' social needs. This is one item that the country can't ignore any longer. Nearly one quarter of the population (23.5%) is older than 65 years, a figure which is expected to rise to 35% by 2050.

The community units will be divided into basic facilities (spokes) and more complete centers (hubs) that combine primary care services with specialist services and everything needed for a basic diagnosis. Two billion euros were set aside to achieve this goal, which is double the amount needed to provide the country with around 400 community hospitals. These small, 20-bed facilities can meet the country's need for beds for patients who are not yet clinically stable or who are in recovery, without blocking hospital beds or discharging patients who cannot yet look after themselves. The plan envisaged that even patients who are discharged home would not be abandoned. The expenditure included 4 billion euros for various telemedicine initiatives. 

Difficulties and Contradictions

The plan hit a roadblock immediately. The Italian Federation of General Practitioners defended private practitioners and opposed the designation of primary care physicians as employees of Italy's national health service. Other trade unions support this change.

Another criticism comes from the fact that the NRRP's funds are meant to help build the new facilities, but they don't cover the costs needed for them to function. The issue, which already has been raised in relation to the creation of new nursery schools, is crucial amid the short supply and underpayment of healthcare professionals.

The inequalities that already affect the country, especially across the north-south divide, seem to be accentuated by the distribution of projects. For example, 65.7% of all community units should be hubs, with greater service provision. In Sardinia, Abruzzo, Basilicata, and Sicily, however, more than 60% of the planned facilities are just spokes. In Calabria, this figure reaches 77%, whereas all facilities planned for Lombardy, Piedmont, Umbria, and Veneto are designated as hubs.

Finally, it is precisely the strength of the model set out by the European Union that threatens to compromise its outcomes. On one hand, having funding subjected to strict accountability standards and, above all, a strict and tight timeline prevents the chronic delays for which Italy is famous. On the other hand, it makes many initiatives unfeasible because of the threat of not closing construction sites in time and thus losing all the promised money.

Everyone Is Dissatisfied

The Italian government addressed these issues in the NRRP review presented by Minister Raffaele Fitto to the European Commission in early August. The draft proposes a cut of €16 billion to various initiatives, from funding for suburban areas to money to counter hydrogeologic disturbance and environmental initiatives. The government claims that it's not a question of cuts because the projects will find other resources not requiring such tight deadlines.

"With the remodeling of the NRRP, we intend to keep the current system set out by the Health Mission and seek to tap into different funding pots, such as funding for healthcare infrastructure (pursuant to Article 20) and cohesion funds. So, no cuts. On the contrary, we are seeking to overcome the current critical issues we have inherited, moving toward other investment programs capable of guaranteeing the resources needed for them to function," said shadow Health Secretary Marcello Gemmato, defending the policy. But the fear of returning to the red tape, blockages, and lack of funds that are too often associated with the public administration system is justified.

In terms of healthcare, the plan means stopping the construction of 414 of the projected 1350 community units and abandoning the hope that these units, among other measures, will ease the burden on hospital emergency departments. The government's axe also falls on the community hospitals, of which 408 remain. This total is almost a hundred fewer than planned. The measure also means goodbye to 76 of the 600 central operational units that were supposed to guarantee coordinated patient care pathways.

Regional leaders are protesting too. Despite being headed by Northern League member Massimiliano Fedriga, they have complained to the government about the decision itself and the way in which it was made without involving the regions, which are responsible for healthcare in Italy.

In short, this is a proposal that no one is happy about. We shall see what Brussels thinks about it all.

This article was translated from Univadis Italy, which is part of the Medscape professional network.

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