Towards a health agenda

Who should make decisions on health? Should the management model be centralised or decentralised? And what role should the private sector play in the issuing and funding of welfare and health services? These are issues,' said Turati, 'which in Italy are mainly debated in terms of discussion and confrontation between the state and regional administrations. However, the European Union also has an increasingly pervasive role, without neglecting the role of the World Health Organisation, especially when it comes to managing global emergencies, or global prevention. In general terms, there are decisions that need to be taken at the 'macro' level, for example those relating to vaccination programmes. On the other hand, governance, the management of decisions taken at a higher level, may involve local entities. Decentralisation can indeed bring benefits in terms of both the effectiveness of intervention and its cost-effectiveness. For this to happen, however, it is necessary to invest in the local area, general practitioners, and cooperation between all the players, also outside hospitals.

Vecchietti spoke about the role of the private sector, focusing on aspects relating to insurance. In Italy, the sector generates 140 billion euro. Italy ranks 22^nd among European countries in terms of damage insurance, with only 33 billion invested by savers, while it ranks eighth in terms of life insurance. Of this 33 billion, moreover, only a very small proportion is invested in health insurance. In short, we do not have a culture that values additional healthcare cover to complement that offered by the public sector. There is also little connection between healthcare insurance and public healthcare facilities, unlike the UK or France, where integration between the two 'worlds' is a fully operational aspect of the overall welfare system.

Hospitals, which Ricciardi discussed, are another fundamental pillar of the health system. In Italy, the system is very uneven. On the one hand, we have peaks of excellence, while on the other there are dilapidated establishments. Another problem is the networking of big data. In Italy, where healthcare is regionalised, we have 21 different IT systems, which do not communicated with each other, to the extent that someone who begins the vaccination process in one region and then moves to another does not take their vaccination data with them.

Nuti also talked about the regions. Clearly there is a need for centralised governance of operations when there is a pandemic to be managed, with a clear institutional point of reference, capable of making decisions to which local authorities must also adhere. However, we should not forget that centralisation does not always guarantee good results. Healthcare has high fixed costs that are difficult to reduce (with savings already having been made in the past). These costs cannot subsequently be recovered, as takes place with a production line. In general, the Italian health system is characterised by its high level of rigidity, and this is where action could possibly be taken.

This rigidity has not been reflected in the behaviour of young people, commented Capua: the next generation has responded positively to the appeal to be vaccinated, perhaps also for practical reasons, because vaccination means greater freedom. However, the future is not particularly encouraging: a new pandemic is destined to arrive sooner or later. This is certain, because the passage of viruses from animals to man is a 'normal' phenomenon, and globalisation does the rest. However, we cannot afford to deal with another pandemic as we have with Covid-19. We must therefore use the powerful transformational energy the pandemic has brought with it to construct a different future. Clearly, it is difficult to do so if those governing certain 'key' countries around the world repudiate the work of science and doctors, as has taken place in this last period. Before anything else, it is necessary to believe in pandemics. Then there are important technological issues to be resolved. It is not possible to imagine global vaccination programmes entrusted to refrigerators and the 'cold chain'. We need to invest more and better in science, the management of healthcare systems, and accessibility to treatment - not just vaccines - for everyone, in order to be ready to face the challenges that we will undoubtedly encounter.