How Will the Italian Regional Elections Affect Healthcare?

MILAN — Italy’s right-wing parties won big during the regional elections held in February in two of Italy’s most populous regions, Lazio and Lombardy. The victories confirmed far-right Prime Minister Giorgia Meloni’s leadership. National attention focused on turnout in Lombardy. As the first local election since the beginning of the pandemic in the wealthiest and most populous region (with 10 million people), it was considered a political barometer.

Lombardy, home of Italy’s financial and fashion capital Milan, boasts leading-edge industry and world-class hospitals, with a €25-billion budget, of which €20 billion are allocated to social services and healthcare. Yet Lombardy was the hardest-hit region in Europe during the first wave of the coronavirus pandemic. The region became the European epicenter of the pandemic after February 20, 2020, when Codogno, a town near Milan, recorded the first case of COVID-19 in Italy and was placed into quarantine. Doctors were forced to ration ventilators and hospital beds and had to decide who lived and who died.

Nevertheless, the region’s incumbent president, Attilio Fontana of the far-right Northern League, was re-elected with more than 55% of the vote. His victory was notable for the fact that only 40% of citizens voted, which was the lowest turnout ever recorded (turnout in the 2018 elections was more than 70%). The center of the re-elected president’s program is the implementation of “a social-health system closer to the citizen: the home becomes the place of care and assistance, and the patient will eventually be referred to local health structures.” Fontana also aims to potentiate the public–private partnership.

Italy maintains a universally accessible national health service (Servizio Sanitario Nazionale). The pandemic has uncovered the strengths and weaknesses of the healthcare system, which is region-based. According to many critics, the catastrophic management of the initial spread of the pandemic in Lombardy was partly a consequence of having assigned much of the public healthcare system to private, profit-making companies and failing to coordinate their services.

“Specializations such as hygiene and prevention, primary healthcare, and outpatient clinics have been considered not strategic assets over the years,” Michele Usuelli, a neonatologist in Milan and member of the center-left Più Europa party in the regional assembly, told Medscape Medical News. Indeed, huge investments have flowed into remunerative specialties like cardiac surgery and oncology. “That is why we have a healthcare system very well prepared to treat the most complicated diseases but completely ill equipped to fight a pandemic. In addition, Lombardy and [the national government] never agreed on many issues such as the initial testing strategy, while blood was flowing,” he said.

“Retrospectively, I think that Lombardy did not perform much worse than other places after all,” Giuseppe Remuzzi, director of the Mario Negri Institute in Bergamo, Italy, told Medscape. “Let’s not forget that Lombardy found itself in this situation first in Europe, alone. I’m not saying that Lombardy performed well, but it cannot be said that Lombardy did not try everything possible in the most critical phases of the pandemic. It had difficulties at the beginning, especially with the organization of vaccinations, but it was the first region that exceeded 90% of vaccinated population, eventually.”

Remuzzi blamed the general weakness of local medicine for the shortcomings. It is true that the “territorial assistance” — that is, support for local healthcare such as general practitioners, health centers, and emergency medical services — has been extremely weak, if not absent in many situations. According to Remuzzi, the roots of Lombardy’s healthcare model go back 25 years, long before the current government, when a charismatic politician named Roberto Formigoni became the regional governor under Silvio Berlusconi’s Forza Italia party. Formigoni’s regional law allowed private providers to serve patients while collecting payment from the regional healthcare system financed by taxpayers. This model was perceived as innovative, bringing competition and thus forcing public hospitals and clinics to improve.

But rampant privatization was accompanied by widespread corruption. The model shaped by Formigoni persisted even when he left office in 2013 and spent 5 years in prison for corruption. It has been associated with the deterioration of primary care and prevention. Lombardy is now one of the Italian regions with the fewest family doctors (one family doctor per 1413 inhabitants, compared with a national average of one doctor per 1232 inhabitants) and prevention services (one prevention service per 1.2 million). 

Fontana’s concept of home-centered healthcare is right but must develop within a structured program and cannot be implemented without a reform, said Remuzzi. General practitioners in Italy work as independent contractors in a national health service, and it is difficult for the latter to provide functional management of the former. Moreover, critics fear that the current government of Lombardy will keep knocking down the national health service in favor of the private sector.

“The privatization has crept into the public system, and citizens in Lombardy have become accustomed to paying a copay to speed up healthcare services even within the national health service, for which they already pay through taxes,” said Usuelli. Many would like to see the Lombardy model abandoned, because it is less and less democratic. By its nature, the private sector must increase profits, while on the contrary, the turnover should be reduced (less bypass surgery to coronary arteries, fewer hip replacements, fewer aortic valve surgeries for those over 80 years of age, and so on) and prevention should be promoted, doctors told Medscape.

Italian prosecutors have closed a COVID-19 investigation started a year ago that accuses administrators, including Giuseppe Conte, the prime minister at that time, and the regional governor Fontana, of wrongdoing in the early days of the pandemic. The prosecutors assert that officials extended the lockdown from Codogno to other industrial areas of the region too late, and therefore caused preventable deaths. So, why was the regional governor re-elected? “First of all, we are still close to the political elections held in September, and the right-wing wind is still very strong in Italy. Then, I believe that there is a process of collective removal underway. People could vote for a better healthcare system, but somehow, they just want to forget,” said Usuelli.

For more coverage of Italian medical news, visit Univadis Italy.

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