ROME — When darkness descends and the stone pines are no longer visible through the windows of San Giovanni Addolorata Hospital, nighttime in the emergency wards reveals a health service verging on breakdown.
Trolleys bearing elderly patients spill out into the corridors. A nurse grows visibly exhausted as she is forced to juggle several wards by herself. With no beds available, a sickly twenty-something curls up to sleep on the floor.
It looks like a scene out of the Covid-era — but four years later, San Giovanni Addolorata’s situation is typical of Italian hospitals.
In recent weeks, the stress on Italy’s health care system has come to the fore after the government’s latest budget proposal appeared to abandon major spending plans for the sector in the context of a broader fiscal squeeze, one of many across Europe. Enraged and overworked, thousands of health care workers are set to strike this Wednesday.
Many in the sector had hoped for measures to improve low pay, onerous conditions and staff shortages. Health Minister Orazio Schillaci had trumpeted an extra €3.7 billion in health care spending in next year’s budget, and Prime Minister Giorgia Meloni had promised that ordinary Italians would be spared the worst effects of any cuts. But critics say the measures that made it into the final text were really worth just over €1.2 billion, well below what they argue is needed to keep the system afloat.
The increase in funding in absolute terms is “flaunted as a great achievement, but is in reality a mere illusion,” Gimbe Foundation president Nino Cartabellotta told a parliamentary budget committee earlier this month. He predicted that even the best run health authorities will have to cut services.
The unions, meanwhile, have blasted the government for failing to budget for an increase in hospital hiring capacity, even after it was enshrined in law earlier this year. Lawmakers can still push for amendments until December.
Schillaci, however, has defended the budget in parliament, saying his ministry inherited a system run down by years of cuts. Prime Minister Giorgia Meloni insisted last week that the proposed spending was an increase both in absolute terms and adjusted for inflation, adding that billions had been earmarked for wage increases until 2030.
“Creeping privatization”
Watchdogs argue that the hole in resources is putting the nation’s health at risk, with some 4.3 million Italians reportedly renouncing treatment because of waiting lists (these can last up to 715 days in the case of ultrasound appointments). Elly Schlein, leader of the center-left Democratic Party, told POLITICO the government had broken its promises, condemning the “dangerous disinvestment” in public health care, and “creeping privatization.”
“The welfare state is in great crisis,” said Pierino Di Silverio, a Naples-based surgeon and the national secretary of medical union Anaao. “It’s a pillar of our social model — and it’s being progressively de-financed.”
Certainly, the original aspiration underlying Italy’s National Health Fund — to provide universal coverage, funded by general taxation — is struggling to survive. Italy’s rapid population ageing — nearly a quarter of Italians are over 64 years old — means that demand for services is growing much faster than the tax revenues needed to pay for them.
Against that backdrop, the share of services provided privately has grown steadily over the last decade, and now accounts for around a quarter of all health spending in the country. But the growth of a parallel private system has inevitably drawn away resources — including key staff — from the state sector. Workers in the state system are leaving, either to the private sector or abroad, at a pace of 14 a day, said Di Silverio.
That is compounding historic problems with the uneven distribution of funding across the country, which has tended to entrench divisions between the rich north and the poor south.
The issue is especially severe, Di Silverio said, in emergency wards, which now have up to 100 patients per doctor. The system is “so underfunded and badly equipped that people spend days in the emergency room,” recalled one medic at a major hospital in northern Rome, speaking on condition of anonymity as she wasn’t permitted to speak to the press. With patients often consigned to little more than a chair, the staffer said, frustrated relatives are known to assault overworked doctors, promoting more staff departures and increasingly dire conditions. “Nobody wants to do emergency medicine,” she said.
Dead on arrival
Part of the budget strain is thanks to tough EU fiscal rules, brought back this year in a new form after being suspended during the pandemic. As a result of its enormous debt (now standing at nearly €3 trillion, or 139 percent of GDP) and an uncontrolled surge in deficit spending, Italy — along with several other countries — must now cut its deficit by at least 0.5 percent of GDP annually for up to seven years or face sanctions.
But while the rules offer some leeway for increased funding on defense and the green transition, they have little or nothing to say on health. That lack of protection, critics argue, is bringing the state health system closer to breaking point.
Italy isn’t alone among EU countries pushed into difficult public spending trade-offs to rein in debt, and the Organization for Economic Cooperation and Development (OECD) notes that the Italian health care system is not all bad, boasting the third highest healthy-life expectancy as well as above-average spending on prevention.
But fiscal constraints have ensured that overall spending on health has fallen as a share of GDP since 2009, in contrast to most European countries, which have done better in accommodating the needs of graying populations.
Analysis by the Gimbe Foundation, an independent watchdog, suggests spending on the National Health Fund, specifically,will now fall to 5.7 percent of GDP by 2029, from 6.1 percent this year and well below the 7 percent recommended by the authors of a recent study published in The Lancet. Overall spending on health, at 9.0 percent of GDP, is more than two full percentage points below the level in France, Germany and the U.K, according to OECD data.
That’s partly because Italy has to spend so much more on servicing its existing debts. Raffaele Nevi, an MP with the center-right Forza Italia party, part of Meloni’s government, insisted that it’s essential to stick to the rules, to rebuild Italy’s credibility with financial markets and keep its future borrowing costs low. Despite the huge budget gap, the infamous ‘spread’ between Italian and German bond yields is currently as low as at any time since the European Central Bank stopped its net buying of government debt.
Do not resuscitate
To opposition figures and union leaders in negotiations with the government, the disappointment marks a covert return to the kind of austerity policies that have left much of Italy’s infrastructure crumbling or broken in recent decades. In the latest budget draft, outlays for new parents, pensions and teachers were also much smaller than expected. Schlein, the opposition leader, blasted as “unacceptable” a pension increase that amounts to just €3 a month, while government departments and local councils are gearing up for several billion euros in cuts.
“They say they’re constrained by the European Union,” grumbled Guido Quici, president of the doctors’ union Cimo, recalling conversations with government officials.
Quici also expressed frustration that sectors with more powerful lobbies — or EU mandates — were barely scratched by the budget. Banks and insurers will only suffer a temporary shortfall, the tobacco industry avoided long-called-for tax increases. Military spending, meanwhile, is set to rise by over €2 billion each year on average until 2039, after three decades of withering on the vine.
Some argue that the Italian situation reflects a broader loss of interest in health care and welfare amid a growing push for investments in hotter sectors. An influential report authored by former Italian PM Mario Draghi earlier this year, seen in Brussels as an economic blueprint for the next decade, makes only passing reference to health, focusing on developing new technologies.
A spokesman for the European Commission said it was “assessing Italy’s draft budget plan and medium-term fiscal plan” and will present its assessment before the end of November.
“My feeling,” said Yannis Natsis, director of the European Social Insurance Platform, a Brussels-based industry group, “is the [EU-wide] health budget will be significantly reduced because of other competing priorities like defense, security, and the industrial agenda.”
Rory O’Neill contributed to this report.
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