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Decades of Tight Fiscal Policy Have Left the Health Care System in Italy Ill-Prepared to Fight the COVID-19 Outbreak

Decades of Tight Fiscal Policy Have Left the Health Care System in Italy Ill-Prepared to Fight... DOI: 10.1007/s10272-020-0886-0 Forum End of previous Forum article Franz Prante, Alessandro Bramucci and Achim Truger* Decades of Tight Fiscal Policy Have Left the Health Care System in Italy Ill-Prepared to Fight the COVID-19 Outbreak The Sars-CoV-2 pandemic and the resulting COVID-19 Italian national health system (Sistema sanitario nazionale, disease is overwhelming some European health systems SSN) has been unable to cope with the care of COVID-19 in an unprecedented manner. The situation remains par- patients. This article takes a closer look at the connec- ticularly serious in Italy. In the most affected regions, the tion between health care and strong budget consolida- tion in the case of Italy. Although austerity was particularly strong in the aftermath of the economic crisis of 2008 and its consequences in the euro area, Italian fi scal policies Franz Prante, Berlin School of Economics and Law have been characterised by tough consolidation peri- (HWR); and University of Duisburg-Essen, Germany. © The Author(s) 2020. Open Access: This article is distributed under the Alessandro Bramucci, Berlin School of Economics terms of the Creative Commons Attribution 4.0 International License and Law (HWR), Germany. (https://creativecommons.org/licenses/by/4.0/). Open Access funding provided by ZBW – Leibniz Information Centre Achim Truger, University of Duisburg-Essen; and for Economics. German Council of Economic Experts, Wiesbaden, * This contribution is based on preliminary parts of an ongoing research Germany. project on the Italian economy funded by Friedrich-Ebert-Stiftung in Germany. ZBW – Leibniz Information Centre for Economics 147 Forum Figure 1 Figure 2 Government and compulsory health care Government and compulsory health care expenditure per capita and primary balance in Italy expenditure per capita in selected countries constant prices (2010) and percent of potential GDP constant prices (2010) euros % euros 2,000 Cyclically adjusted primary balance 8 4,000 (right axis) 1,900 6 3,500 1,800 3,000 1,700 4 2,500 1,600 1,500 2,000 1,400 0 1,500 1,300 -2 1,000 Government/compulsory expenditure on health, 1,200 per capita, constant prices (left axis) 1,100 -4 Notes: the OECD classifi es government funded and compulsory insur- ance funded health care expenditures into the same category. Belgium France Germany Sources: OECD; IMF. Netherlands Portugal Spain Greece Italy Euro area ods ever since the 1990s. Over the years, the SSN has Notes: Data for Malta and Cyprus are not available and are not included in the euro area average. Euro membership as of 2020. Breaks present in undergone a profound transformation aimed at contain- the data. For 2018, provisional data or OECD estimates. ing costs and increasing effi ciency. The question now is Sources: OECD; authors’ calculations. whether the consequences of these measures have left the SSN unprepared to face the scourge of COVID-19. Italy’s SSN was founded in 1978. Based on the national constitution (Article 32), the state guarantees the univer- what the government extracted from the national econ- sal right and largely free access to health care services. omy in terms of taxes has been larger than what people During the 1990s, a fi rst series of far-reaching reforms received in public services for almost three decades. Fig- was implemented in an attempt to contain costs in the ure 1 also shows that periods with cuts in real health care face of the growing healthcare needs of an ageing popu- expenditure tend to correspond with or follow periods of lation and rapidly improving technologies (Pavolini and strong budget consolidation in the fi rst half of the 1990s Vicarelli, 2013). These reforms were largely in line with the and in the euro crisis after 2010. market-liberal ‘New Public Management’ approach and their primary objective was to limit Italy’s public defi cits The development of Italian health care expenditure is re- and debt (Pavolini and Vicarelli, 2013). Cost containment ported in Figure 2 together with data for selected Euro- was therefore motivated by the macroeconomic context pean countries and the euro area average. Three phases of the time, characterised by Italy’s efforts to meet the can be observed in the evolution of Italian expenditure. In Maastricht criteria and the requirements of the Stability the 1990s, unlike most other industrialised countries, Italy and Growth Pact, which led to an overall tightening of experienced a decline in public and compulsory health public spending. More recently, the global fi nancial crisis care expenditure (measured in constant euros per capita). and the policy response to the euro crisis put a further It was not until the end of the 1990s that a slight upward strain on the Italian economy and signifi cant restrictions trend began when spending increased in parallel to the on health care spending returned to the national agenda other European countries until the late 2000s. From 2010 (De Belvis et al., 2012). Since the early 1990s, the Italian onwards, a new phase of spending containment began, government has registered almost 30 consecutive years lasting until 2015. In this period, public health care spend- of primary budget surpluses (Figure 1). This signals that ing was similarly affected in Portugal and Spain and to a larger extent in Greece, i.e. the countries hardest hit by the euro crisis and the subsequent austerity policies. 1 The European Commission (2019) in its Country Report Italy 2019 By contrast, in this period a rapid increase in public and fi nds the SSN to be generally effi cient and its outcome in terms of compulsory healthcare spending per capita took place in health indicators good, albeit with regional disparities in the provision of health services affecting equity and effi ciency. Germany, France and Belgium. Intereconomics 2020 | 3 2018 Forum Figure 3 Percentage change in government and compulsory health care expenditure per capita in selected countries constant euros (2010) 1990-2000 2000-2010 % % 120 80 60 40 0 0 2010-2018 1990-2018 %% 30 160 -10 -20 -30 -40 0 Notes: For Belgium, the value for 1990 is missing and was replaced with the value for 1993. Sources: OECD; authors’ calculations. Figure 3 shows the percentage change in government research and development and other components) has and compulsory health care per capita for these three suffered a drastic setback. From 2008 to 2018, total pub- different phases and for the entire period between 1990 lic health care expenditure in nominal terms (i.e. including and 2018. From 1990 to 2000, a fi rst phase of expendi- infl ation) increased by only 5.3% in Italy, while in Germa- ture containment took place in Italy, in which public ex- ny it increased by 46.8% (Figure 4a). Moreover, COFOG penditure increased by only 8.7%. After a slightly expan- data provides evidence of the extent of cuts in hospital sive second phase from 2000 to 2010, in which spending services. Unlike Northern European countries, Italy (to- per capita in Italy increased by 27.1%, the growth of pub- gether with Portugal and even more so Greece) has re- lic health expenditure registered a reduction in the third duced public spending for hospital services. time interval (as was the case in Portugal, Greece and Spain). In this period, characterised by the most recent From 2011 to 2018, cuts in public hospital services have set of budget cuts, per capita spending in Italy decreased contributed substantially to the negative dynamics of the by 8.2% – less strongly than in Greece but more than in percentage growth rate of the total public expenditure for Spain and Portugal. In contrast, the group of Northern health care (Figure 4b). Although austerity policy placed countries registered an increase. Altogether, from 1990 a great burden on the health care system, the share of to 2018, public and compulsory health care expenditure health care expenditures in total government spending per capita in Italy increased by less than 26.8%, which is by far the lowest value among the European countries 2 The Classifi cation of the Functions of Government (COFOG) health aggregate (GF07 and relative groups) classifi es all types of govern- reported in Figure 3. ment expenditure for the purpose of health (including expenditure on employees, intermediate consumption, government expenditure on In the last decade, the extent of cuts in the SSN was par- gross capital formation, etc.). The delineation of government expendi- ture in the COFOG classifi cation differs from the System of Health Ac- ticularly dramatic. In the wake of the fi nancial and eco- counts. nomic crisis of 2008, total public healthcare expenditure 3 According to the COFOG classifi cation, day hospitalisation is classi- in Italy (including investments, intermediate consumption, fi ed under hospital services. ZBW – Leibniz Information Centre for Economics Italy Belgium Spain Germany Netherlands France Greece Greece Portugal Italy Portugal Spain Netherlands Belgium France France Portugal Germany Italy Germany Belgium Spain Greece Italy Netherlands Greece Belgium Spain Germany France Netherlands Portugal Forum Figure 4a Figure 4b Percentage change of total government spending for Composition of the growth rate of total government health care and for hospital services, 2008-2018 spending for health care in Italy, nominal values Health not elsewhere classified R&D health Public health services Hospital services Outpatient services Medical products, appliances and equipment Total -10 -20 -30 Spending for hospital services -40 Total government health care spending -50 -2 Note: Second level COFOG. Sources: Eurostat COFOG; authors’ calculations. Sources: Eurostat COFOG; authors’ calculations. has increased from 10% in 1995 to 14.7% in 2008 and of acute care hospitals in Italy fell below the EU average. remained above 14% after 2008, according to COFOG The trend continued to decline throughout the years of data. This may indicate that health care provision was the euro crisis. important to the government despite general spending constraints. However, this did not prevent Italian expen- The availability of acute care beds was reduced even ditures from falling below the international trend. more drastically than hospital capacity (Figure 6). Al- though a pronounced trend towards reducing acute care In the EU, almost one-third of public health care expendi- beds can be observed in many European countries, few ture is used to cover the running expenses of inpatient European countries have reduced the number of available curative institutions (European Hospital and Healthcare beds as much and to such a low level as Italy. In 1990, It- Federation, 2018). Over the years, hospitals have been aly had seven beds per 1,000 inhabitants, a value close to subject to increasing pressure and have often been seen Germany and above the EU average. In 2017, the number as a major potential source for cuts in public health sys- of acute care beds had dropped to 2.6 per 1,000 inhab- tems (see McKee, 2004; Popic, 2020). Cost containment itants, signifi cantly lower than in Germany with six beds strategies revised the use and provision of inpatient hos- available per 1,000 persons and much closer to the his- pital care in favour of day hospital and outpatient ser- torically low value of Spain. Thus within a rather short time vices, thereby consistently sacrifi cing hospital capacity. period, Italy found itself at the lower end of the spectrum Data from the World Health Organization (WHO) show in Europe. that since the beginning of the 1990s, the number of hos- pitals has been drastically reduced throughout Europe, There is also a considerable difference in the provision but particularly in Belgium and Italy. Acute care hospitals of intensive care beds, with Italy again at the tail end in are currently a central element in the fi ght against COV- Europe (Rhodes et al., 2012; OECD, 2020). Although in re- ID-19. A higher number of acute care hospitals could have cent years the number of intensive care beds in Italy has also facilitated the isolation of infected patients, reducing remained relatively constant (Figure 7), intensive care ca- the risk of contagion. Figure 5 shows that after starting pacity has not been expanded (in contrast to e.g. Germa- from a level similar to Germany in 1990, Italy has reduced ny) despite warnings of possible bottlenecks in accom- per capita hospital capacity much more than many other modation capacity of intensive care patients (Rhodes et countries within two decades. From 2010 on, the number al., 2012). Intereconomics 2020 | 3 Greece Italy Portugal Euro area France Belgium Germany Netherlands 2018 Forum Figure 5 Figure 6 Acute care hospitals per 100,000 inhabitants, eight Acute care beds per 1,000 inhabitants, eight largest largest EMU countries and EU average EMU countries and EU average 4.0 France 3.5 Belgium 3.0 Germany Germany 2.5 EU average (post 2004) Italy 6 Italy 2.0 Belgium Greece 1.5 EU average France Portugal Greece Spain 4 1.0 Netherlands Portugal Netherlands 0.5 Spain Note: EU membership as of 2020 with country data available. Sources: WHO; authors’ calculations. Sources: OECD; authors’ calculations. Italy, as well as other European countries, would have is a matter of controversy among lung specialists and in- been better prepared for adequate treatment of COVID-19 tensive care physicians (Gattinoni et al., 2010). The current patients in severe and critical condition if the capacity of research gap on COVID-19 may therefore also require a acute and emergency care had not been reduced. Oxy- comprehensive diagnosis of patients by lung specialists, gen-assisted beds are particularly relevant for the inpatient which could lead to better treatment outcomes (see also treatment of COVID-19. For some patients, breathing diffi - Begley, 2020). In this context, the substantial reduction in culties worsen in the course of the illness, making intensive the number of pneumological beds during the phase of in- medical care necessary. The public discussion therefore tensifi ed austerity after 2010 in Italy is particularly tragic. focuses primarily on the availability of intensive care ca- According to the data of the Italian Ministry of Health, the pacities and mechanical ventilation equipment. However, number of pneumological beds has decreased from 4,414 the speed at which machine ventilation should be provided in 2010 to 3,573 in 2018 – a reduction of 19%. The reduction of resources in the public health system and Figure 7 in particular in the operation of public hospitals in Italy has Total number of intensive care beds and been going on for almost 30 years. The Italian population pneumological beds in Italy and Germany is currently paying the price of prolonged tight budget poli- cies in the SSN. The one-sided focus on fi scal constraints and debt reduction has deprived the Italian health sector of 30,000 an important part of its capacity to offer adequate protec- 25,000 tion to the population. The sizeable reduction of resources 20,000 has caused severe diffi culty to the SSN in effectively tack- ling the consequences of COVID-19. The outbreak of the 15,000 health crisis has sounded a wake-up call that cannot re- 10,000 main unheard. 5,000 2010 2011 2012 2013 2014 2015 2016 2017 2018 References Intensive care beds in Italy Pneumological beds in Italy Begley, S. (2020, 8 April), With ventilators running out, doctors say the Intensive care beds in Germany machines are overused for Covid-19, STAT, https://www.statnews. com/2020/04/08/doctors-say-ventilators-overused-for-covid-19/ (14 April 2020). Sources: Italian Ministry of Health; Destatis. ZBW – Leibniz Information Centre for Economics 2018 Forum De Belvis, A. G., F. Ferrè, M. L. Specchia, L. Valerio, G. Fattore and W. OECD (2020), Beyond Containment: Health systems responses to COVID-19 Ricciardi (2012), The fi nancial crisis in Italy: Implications for the in the OECD, https://read.oecd-ilibrary.org/view/?ref=119_119689- healthcare sector, Health policy, 106, 10-16. ud5comt f8 4 &T itle = Beyond%20 C ontainment:Health%20 sys- Gattinoni, L., S. Coppola, M. Cressoni, M. Busana and D. Chiumello tems%20responses%20to%20COVID-19%20in%20the%20OECD (2020), Covid-19 Does Not Lead to a “Typical” Acute Respiratory (2 April 2020). Distress Syndrome, American Journal of Respiratory and Critical Care Pavolini E. and G. Vicarelli (2013), Italy: A Strange NHS with Its Paradox- Medicine, advance online publication. es, in: E. Pavolini and A. M. Guillén (eds.), Health Care Systems in Eu- European Commission (2019), Country Report Italy 2019: Including an In- rope under Austerity, Work and Welfare in Europe, Palgrave Macmillan. Depth Review on the prevention and correction of macroeconomic Popic, T. (2020), European health systems and COVID-19: Some early les- imbalances, SWD(2019) 1011 fi nal. sons, EUROPP blog, https://blogs.lse.ac.uk/europpblog/2020/03/20/ European Hospital and Healthcare Federation (2018), Hospital in Europe, european-health-systems-and-covid-19-some-early-lessons/ (29 Health care data 2018. March 2020). McKee, M. (2004), Reducing hospital beds: What are the lessons to be Rhodes, A., P. Ferdinande, H. Flatten, B. Guidet, P. G. Metniz and R. P. learned?, European Observatory on Health Systems and Policies Policy Moreno (2012), The variability of critical care bed numbers in Europe, brief, 6. Intensive Care Medicine, 38, 1647-1653. Intereconomics 2020 | 3 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Intereconomics Springer Journals

Decades of Tight Fiscal Policy Have Left the Health Care System in Italy Ill-Prepared to Fight the COVID-19 Outbreak

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Abstract

DOI: 10.1007/s10272-020-0886-0 Forum End of previous Forum article Franz Prante, Alessandro Bramucci and Achim Truger* Decades of Tight Fiscal Policy Have Left the Health Care System in Italy Ill-Prepared to Fight the COVID-19 Outbreak The Sars-CoV-2 pandemic and the resulting COVID-19 Italian national health system (Sistema sanitario nazionale, disease is overwhelming some European health systems SSN) has been unable to cope with the care of COVID-19 in an unprecedented manner. The situation remains par- patients. This article takes a closer look at the connec- ticularly serious in Italy. In the most affected regions, the tion between health care and strong budget consolida- tion in the case of Italy. Although austerity was particularly strong in the aftermath of the economic crisis of 2008 and its consequences in the euro area, Italian fi scal policies Franz Prante, Berlin School of Economics and Law have been characterised by tough consolidation peri- (HWR); and University of Duisburg-Essen, Germany. © The Author(s) 2020. Open Access: This article is distributed under the Alessandro Bramucci, Berlin School of Economics terms of the Creative Commons Attribution 4.0 International License and Law (HWR), Germany. (https://creativecommons.org/licenses/by/4.0/). Open Access funding provided by ZBW – Leibniz Information Centre Achim Truger, University of Duisburg-Essen; and for Economics. German Council of Economic Experts, Wiesbaden, * This contribution is based on preliminary parts of an ongoing research Germany. project on the Italian economy funded by Friedrich-Ebert-Stiftung in Germany. ZBW – Leibniz Information Centre for Economics 147 Forum Figure 1 Figure 2 Government and compulsory health care Government and compulsory health care expenditure per capita and primary balance in Italy expenditure per capita in selected countries constant prices (2010) and percent of potential GDP constant prices (2010) euros % euros 2,000 Cyclically adjusted primary balance 8 4,000 (right axis) 1,900 6 3,500 1,800 3,000 1,700 4 2,500 1,600 1,500 2,000 1,400 0 1,500 1,300 -2 1,000 Government/compulsory expenditure on health, 1,200 per capita, constant prices (left axis) 1,100 -4 Notes: the OECD classifi es government funded and compulsory insur- ance funded health care expenditures into the same category. Belgium France Germany Sources: OECD; IMF. Netherlands Portugal Spain Greece Italy Euro area ods ever since the 1990s. Over the years, the SSN has Notes: Data for Malta and Cyprus are not available and are not included in the euro area average. Euro membership as of 2020. Breaks present in undergone a profound transformation aimed at contain- the data. For 2018, provisional data or OECD estimates. ing costs and increasing effi ciency. The question now is Sources: OECD; authors’ calculations. whether the consequences of these measures have left the SSN unprepared to face the scourge of COVID-19. Italy’s SSN was founded in 1978. Based on the national constitution (Article 32), the state guarantees the univer- what the government extracted from the national econ- sal right and largely free access to health care services. omy in terms of taxes has been larger than what people During the 1990s, a fi rst series of far-reaching reforms received in public services for almost three decades. Fig- was implemented in an attempt to contain costs in the ure 1 also shows that periods with cuts in real health care face of the growing healthcare needs of an ageing popu- expenditure tend to correspond with or follow periods of lation and rapidly improving technologies (Pavolini and strong budget consolidation in the fi rst half of the 1990s Vicarelli, 2013). These reforms were largely in line with the and in the euro crisis after 2010. market-liberal ‘New Public Management’ approach and their primary objective was to limit Italy’s public defi cits The development of Italian health care expenditure is re- and debt (Pavolini and Vicarelli, 2013). Cost containment ported in Figure 2 together with data for selected Euro- was therefore motivated by the macroeconomic context pean countries and the euro area average. Three phases of the time, characterised by Italy’s efforts to meet the can be observed in the evolution of Italian expenditure. In Maastricht criteria and the requirements of the Stability the 1990s, unlike most other industrialised countries, Italy and Growth Pact, which led to an overall tightening of experienced a decline in public and compulsory health public spending. More recently, the global fi nancial crisis care expenditure (measured in constant euros per capita). and the policy response to the euro crisis put a further It was not until the end of the 1990s that a slight upward strain on the Italian economy and signifi cant restrictions trend began when spending increased in parallel to the on health care spending returned to the national agenda other European countries until the late 2000s. From 2010 (De Belvis et al., 2012). Since the early 1990s, the Italian onwards, a new phase of spending containment began, government has registered almost 30 consecutive years lasting until 2015. In this period, public health care spend- of primary budget surpluses (Figure 1). This signals that ing was similarly affected in Portugal and Spain and to a larger extent in Greece, i.e. the countries hardest hit by the euro crisis and the subsequent austerity policies. 1 The European Commission (2019) in its Country Report Italy 2019 By contrast, in this period a rapid increase in public and fi nds the SSN to be generally effi cient and its outcome in terms of compulsory healthcare spending per capita took place in health indicators good, albeit with regional disparities in the provision of health services affecting equity and effi ciency. Germany, France and Belgium. Intereconomics 2020 | 3 2018 Forum Figure 3 Percentage change in government and compulsory health care expenditure per capita in selected countries constant euros (2010) 1990-2000 2000-2010 % % 120 80 60 40 0 0 2010-2018 1990-2018 %% 30 160 -10 -20 -30 -40 0 Notes: For Belgium, the value for 1990 is missing and was replaced with the value for 1993. Sources: OECD; authors’ calculations. Figure 3 shows the percentage change in government research and development and other components) has and compulsory health care per capita for these three suffered a drastic setback. From 2008 to 2018, total pub- different phases and for the entire period between 1990 lic health care expenditure in nominal terms (i.e. including and 2018. From 1990 to 2000, a fi rst phase of expendi- infl ation) increased by only 5.3% in Italy, while in Germa- ture containment took place in Italy, in which public ex- ny it increased by 46.8% (Figure 4a). Moreover, COFOG penditure increased by only 8.7%. After a slightly expan- data provides evidence of the extent of cuts in hospital sive second phase from 2000 to 2010, in which spending services. Unlike Northern European countries, Italy (to- per capita in Italy increased by 27.1%, the growth of pub- gether with Portugal and even more so Greece) has re- lic health expenditure registered a reduction in the third duced public spending for hospital services. time interval (as was the case in Portugal, Greece and Spain). In this period, characterised by the most recent From 2011 to 2018, cuts in public hospital services have set of budget cuts, per capita spending in Italy decreased contributed substantially to the negative dynamics of the by 8.2% – less strongly than in Greece but more than in percentage growth rate of the total public expenditure for Spain and Portugal. In contrast, the group of Northern health care (Figure 4b). Although austerity policy placed countries registered an increase. Altogether, from 1990 a great burden on the health care system, the share of to 2018, public and compulsory health care expenditure health care expenditures in total government spending per capita in Italy increased by less than 26.8%, which is by far the lowest value among the European countries 2 The Classifi cation of the Functions of Government (COFOG) health aggregate (GF07 and relative groups) classifi es all types of govern- reported in Figure 3. ment expenditure for the purpose of health (including expenditure on employees, intermediate consumption, government expenditure on In the last decade, the extent of cuts in the SSN was par- gross capital formation, etc.). The delineation of government expendi- ture in the COFOG classifi cation differs from the System of Health Ac- ticularly dramatic. In the wake of the fi nancial and eco- counts. nomic crisis of 2008, total public healthcare expenditure 3 According to the COFOG classifi cation, day hospitalisation is classi- in Italy (including investments, intermediate consumption, fi ed under hospital services. ZBW – Leibniz Information Centre for Economics Italy Belgium Spain Germany Netherlands France Greece Greece Portugal Italy Portugal Spain Netherlands Belgium France France Portugal Germany Italy Germany Belgium Spain Greece Italy Netherlands Greece Belgium Spain Germany France Netherlands Portugal Forum Figure 4a Figure 4b Percentage change of total government spending for Composition of the growth rate of total government health care and for hospital services, 2008-2018 spending for health care in Italy, nominal values Health not elsewhere classified R&D health Public health services Hospital services Outpatient services Medical products, appliances and equipment Total -10 -20 -30 Spending for hospital services -40 Total government health care spending -50 -2 Note: Second level COFOG. Sources: Eurostat COFOG; authors’ calculations. Sources: Eurostat COFOG; authors’ calculations. has increased from 10% in 1995 to 14.7% in 2008 and of acute care hospitals in Italy fell below the EU average. remained above 14% after 2008, according to COFOG The trend continued to decline throughout the years of data. This may indicate that health care provision was the euro crisis. important to the government despite general spending constraints. However, this did not prevent Italian expen- The availability of acute care beds was reduced even ditures from falling below the international trend. more drastically than hospital capacity (Figure 6). Al- though a pronounced trend towards reducing acute care In the EU, almost one-third of public health care expendi- beds can be observed in many European countries, few ture is used to cover the running expenses of inpatient European countries have reduced the number of available curative institutions (European Hospital and Healthcare beds as much and to such a low level as Italy. In 1990, It- Federation, 2018). Over the years, hospitals have been aly had seven beds per 1,000 inhabitants, a value close to subject to increasing pressure and have often been seen Germany and above the EU average. In 2017, the number as a major potential source for cuts in public health sys- of acute care beds had dropped to 2.6 per 1,000 inhab- tems (see McKee, 2004; Popic, 2020). Cost containment itants, signifi cantly lower than in Germany with six beds strategies revised the use and provision of inpatient hos- available per 1,000 persons and much closer to the his- pital care in favour of day hospital and outpatient ser- torically low value of Spain. Thus within a rather short time vices, thereby consistently sacrifi cing hospital capacity. period, Italy found itself at the lower end of the spectrum Data from the World Health Organization (WHO) show in Europe. that since the beginning of the 1990s, the number of hos- pitals has been drastically reduced throughout Europe, There is also a considerable difference in the provision but particularly in Belgium and Italy. Acute care hospitals of intensive care beds, with Italy again at the tail end in are currently a central element in the fi ght against COV- Europe (Rhodes et al., 2012; OECD, 2020). Although in re- ID-19. A higher number of acute care hospitals could have cent years the number of intensive care beds in Italy has also facilitated the isolation of infected patients, reducing remained relatively constant (Figure 7), intensive care ca- the risk of contagion. Figure 5 shows that after starting pacity has not been expanded (in contrast to e.g. Germa- from a level similar to Germany in 1990, Italy has reduced ny) despite warnings of possible bottlenecks in accom- per capita hospital capacity much more than many other modation capacity of intensive care patients (Rhodes et countries within two decades. From 2010 on, the number al., 2012). Intereconomics 2020 | 3 Greece Italy Portugal Euro area France Belgium Germany Netherlands 2018 Forum Figure 5 Figure 6 Acute care hospitals per 100,000 inhabitants, eight Acute care beds per 1,000 inhabitants, eight largest largest EMU countries and EU average EMU countries and EU average 4.0 France 3.5 Belgium 3.0 Germany Germany 2.5 EU average (post 2004) Italy 6 Italy 2.0 Belgium Greece 1.5 EU average France Portugal Greece Spain 4 1.0 Netherlands Portugal Netherlands 0.5 Spain Note: EU membership as of 2020 with country data available. Sources: WHO; authors’ calculations. Sources: OECD; authors’ calculations. Italy, as well as other European countries, would have is a matter of controversy among lung specialists and in- been better prepared for adequate treatment of COVID-19 tensive care physicians (Gattinoni et al., 2010). The current patients in severe and critical condition if the capacity of research gap on COVID-19 may therefore also require a acute and emergency care had not been reduced. Oxy- comprehensive diagnosis of patients by lung specialists, gen-assisted beds are particularly relevant for the inpatient which could lead to better treatment outcomes (see also treatment of COVID-19. For some patients, breathing diffi - Begley, 2020). In this context, the substantial reduction in culties worsen in the course of the illness, making intensive the number of pneumological beds during the phase of in- medical care necessary. The public discussion therefore tensifi ed austerity after 2010 in Italy is particularly tragic. focuses primarily on the availability of intensive care ca- According to the data of the Italian Ministry of Health, the pacities and mechanical ventilation equipment. However, number of pneumological beds has decreased from 4,414 the speed at which machine ventilation should be provided in 2010 to 3,573 in 2018 – a reduction of 19%. The reduction of resources in the public health system and Figure 7 in particular in the operation of public hospitals in Italy has Total number of intensive care beds and been going on for almost 30 years. The Italian population pneumological beds in Italy and Germany is currently paying the price of prolonged tight budget poli- cies in the SSN. The one-sided focus on fi scal constraints and debt reduction has deprived the Italian health sector of 30,000 an important part of its capacity to offer adequate protec- 25,000 tion to the population. The sizeable reduction of resources 20,000 has caused severe diffi culty to the SSN in effectively tack- ling the consequences of COVID-19. The outbreak of the 15,000 health crisis has sounded a wake-up call that cannot re- 10,000 main unheard. 5,000 2010 2011 2012 2013 2014 2015 2016 2017 2018 References Intensive care beds in Italy Pneumological beds in Italy Begley, S. (2020, 8 April), With ventilators running out, doctors say the Intensive care beds in Germany machines are overused for Covid-19, STAT, https://www.statnews. com/2020/04/08/doctors-say-ventilators-overused-for-covid-19/ (14 April 2020). Sources: Italian Ministry of Health; Destatis. ZBW – Leibniz Information Centre for Economics 2018 Forum De Belvis, A. G., F. Ferrè, M. L. Specchia, L. Valerio, G. Fattore and W. OECD (2020), Beyond Containment: Health systems responses to COVID-19 Ricciardi (2012), The fi nancial crisis in Italy: Implications for the in the OECD, https://read.oecd-ilibrary.org/view/?ref=119_119689- healthcare sector, Health policy, 106, 10-16. ud5comt f8 4 &T itle = Beyond%20 C ontainment:Health%20 sys- Gattinoni, L., S. Coppola, M. Cressoni, M. Busana and D. Chiumello tems%20responses%20to%20COVID-19%20in%20the%20OECD (2020), Covid-19 Does Not Lead to a “Typical” Acute Respiratory (2 April 2020). Distress Syndrome, American Journal of Respiratory and Critical Care Pavolini E. and G. Vicarelli (2013), Italy: A Strange NHS with Its Paradox- Medicine, advance online publication. es, in: E. Pavolini and A. M. Guillén (eds.), Health Care Systems in Eu- European Commission (2019), Country Report Italy 2019: Including an In- rope under Austerity, Work and Welfare in Europe, Palgrave Macmillan. Depth Review on the prevention and correction of macroeconomic Popic, T. (2020), European health systems and COVID-19: Some early les- imbalances, SWD(2019) 1011 fi nal. sons, EUROPP blog, https://blogs.lse.ac.uk/europpblog/2020/03/20/ European Hospital and Healthcare Federation (2018), Hospital in Europe, european-health-systems-and-covid-19-some-early-lessons/ (29 Health care data 2018. March 2020). McKee, M. (2004), Reducing hospital beds: What are the lessons to be Rhodes, A., P. Ferdinande, H. Flatten, B. Guidet, P. G. Metniz and R. P. learned?, European Observatory on Health Systems and Policies Policy Moreno (2012), The variability of critical care bed numbers in Europe, brief, 6. Intensive Care Medicine, 38, 1647-1653. Intereconomics 2020 | 3

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IntereconomicsSpringer Journals

Published: May 7, 2020

There are no references for this article.