Countries covered by the HSPM platform

16 July 2024 | Policy Analysis
More power to Italian regions with the approval of “differentiated autonomy”

2.3. Decentralization and centralization

The SSN is highly decentralized, with most of the legislative and executive powers assigned to the regional level of governance with the central government taking on a stewardship role. Historically, based on the long-standing principle of cooperation, the once prevailing top-down approach based on the national health plans has gradually been substituted, starting from the 1990s, by agreements between the national government and the regions known as Health Pacts. Legislative and executive powers have, in fact, been devolved substantially to the regions throughout the years. The most decisive shift occurred in 2001, when a constitutional reform (Title V) largely broadened the scope of regional competences and, simultaneously, circumscribed national ones. This substantially reconfigured the governance structure, de facto shifting the organization and management of health services to the regions. The process of regionalization has created 21 different health systems.[3] Nevertheless, during the COVID-19 pandemic the national government maintained a centralized role in coordinating the health system’s response to the crisis (Box2.1).

Box2.1

The central government is responsible for defining health policy strategies, the national benefits package and the per capita budget, although this decision-making process is undertaken in collaboration with the regions. It maintains a stewardship function to monitor expenditure and reduce geographical inequalities. In addition, it supports financially underperforming regions through financial “recovery plans” (piani di rientro – see section 3.1). These have proven to be effective in reducing expenditure, although in terms of health outcome impacts, one study recorded a slight increase in avoidable mortality in the regions under these plans (Arcà, Principe & Van Doorslaer, 2020). The governance reach of central government was further enhanced in 2016 when financial recovery plans were extended from regions to hospital trusts (hospital recovery plans) and, in 2017, to local health authorities. This means that facilities experiencing budgetary deficits are directly targeted by the central government, giving its General Director three years to restore the organization’s financial situation to acceptable levels. Evaluations are based on volume, quality and outcome parameters (see sections 2.6 and 7.1).

Regional differences in policies and financing have contributed to substantial differences in quality of care among regions and local health authorities, with best performers found mostly in the northern part of the country. For example, the degree of integration between social care providers (municipalities) and local health authorities varies throughout the country and is mostly incomplete.

3. The region of Trentino-Alto Adige/Südtirol contains two autonomous provinces, each with its own health system. ↰

On 19 June 2024, the Italian Parliament approved the differentiated autonomy legislation for regions (Law n. 86 of 26 June 2024), as outlined in Article 116 of the Italian Constitution, paragraph 3. This law sets the principles and procedures for granting greater autonomy to regions that request it, covering 23 policy areas, including healthcare. According to the constitution, healthcare is a shared competency between the regions and the national government, but the new law would make it the exclusive jurisdiction of the regions. This means that the regions will have the exclusive power to legislate, subject only to the general limits imposed by the central government.

The new law establishes that the regions can only be granted greater autonomy after the “essential levels of performance” (livelli essenziali delle prestazioni, LEP in Italian) have been defined, covering essential areas such as education, public transport and social care that need to be guaranteed uniformly across the country. The government will have to establish the LEP within two years via legislative decree. The first Budget Law of the Meloni government, approved at the end of 2022, initiated the steering committee for the determination of the LEP. The new law includes mechanisms to monitor the economic impact of the autonomy agreements with regions, with a committee created to oversee each region’s assets and the human and financial resources it will need to exercise its autonomous functions in the various policy areas, in compliance with public financial objectives and to ensure balanced budgets.

Within healthcare there are already established services that the National Health Service must provide, known as Essential Levels of Care (Livelli essenziali di assistenza, LEAs) and which must be delivered by the regions. These are divided into three categories for the purposes of regional monitoring of care: prevention and public health, district (community) care and hospital care.

The law does not mandate automatic approval of regional requests for more autonomy, but establishes a detailed procedure. However, some critics argue that the law could exacerbate existing territorial inequalities (especially between the richer northern parts of the country and the poorer southern areas). Greater autonomy may worsen existing disparities in healthcare, life expectancy, and the mobility of patients between regions to seek care, potentially leading to a sustainability crisis in the better endowed northern regions and a weakening of the healthcare system in southern regions. For example, greater autonomy in personnel negotiations will cause healthcare professionals to migrate to (northern and central) regions that can offer better economic conditions, further depleting the human capital of in southern regions.

Reflecting on these new governance developments, the Bank of Italy (2023) has pointed out the risks of a highly differentiated institutional setup, such as increased coordination costs and weakened accountability. It also noted the need for national-level coordination on certain competencies, which are seen to be irreconcilable with the transfer of powers to individual regions, citing the fragmented management of the COVID-19 pandemic as an example. There is also a reported lack of clear criteria to verify a region’s readiness for greater autonomy. The law mentions that “the financial framework of the region” is considered, but the formula is deemed vague, non-binding and open to different interpretations.

These concerns are aligned with those expressed, among others, by the European Commission in its Country Recommendations for Italy in May 2023 (European Commission, 2023), stating: “Overall, the reform envisaged by the new framework law risks compromising the ability of public administrations to manage public spending, with a consequent possible negative impact on the quality of Italy's public finances and on regional disparities”.

Authors

References

Bank of Italy (2023). Report to the Senate of the Republic. Bill AS 615 “Provisions for the implementation of the differentiated autonomy of the Regions with ordinary statute pursuant to Article 116, third paragraph, of the Constitution”, 19 June 2023.

European Commission (2023). Commission Staff Working Document Country Report 2023 – Italy accompanying the document Recommendation for a council recommendation on the 2023 National Reform Programme of Italy and delivering a Council opinion on the 2023 Stability Programme of Italy, 24 May 2023.