Let's Not Forget the Elephant in the RoomINADEQUATE INVESTMENT, INABILITY TO COORDINATE DECENTRALIZED SYSTEMS, LOSS OF PRIMARY CARE SPREAD ACROSS THE AREA: THE PROBLEMS THAT EMERGED DURING THE ACUTE PHASE OF THE EMERGENCY ARE NOT NEW. NOT IN ITALY, NOR IN OTHER COUNTRIES SUCH AS THE UNITED STATES AND THE UK, THAT IS, SOME OF THE MOST AFFECTED NATIONS. HERE ARE THE LESSONS WE NEED TO LEARN TO DRAW A NEW ROAD MAP FOR HEALTHCARE SYSTEMS
The pandemic has laid bare an undeniable fact: all economic and social institutions fully depend on the activities performed by people. Without people, or better, without healthy people, society and the economy cannot work.
No matter how obvious this may sound, putting population health and healthcare systems at the core of government actions cannot be taken for granted.
Cost containment pressures and austerity measures adopted in recent years have had a significant impact on the amount of resources available for healthcare. These trends were particularly evident in Italy, UK and US, the three countries that ranked among the first in number of deaths from COVID-19 in the world. At present, Italy spends less on healthcare than most other western European nations: at €3,428 per capita, remains well below Germany’s €5,986 per capita.
The United Kingdom (UK) has likewise implemented austerity measures over the last 10 years, employing contractionary measures that, though the National Health Service (NHS) budget was not reduced, kept increases in funding below previous levels.
Public health expenditure has also been declining in the US. Funding for core emergency preparedness, through the Public Health Emergency Preparedness (PHEP) Cooperative Agreement Program of the Centers for Disease Control (CDC), significantly declined from $940 million in 2002 to $667 million in 2017, compromising state and local health departments’ preparedness for emergencies.
The current epidemic has demonstrated that debilitated healthcare systems can be brought to the brink of collapse with unforeseen consequences for the entire society.
Clear stewardship is essential, especially in decentralized systems
In times of public health emergency, the effectiveness of decentralized systems can be measured by the promptness and determination of the coordinator (i.e., the central government) in creating the conditions to face the emergency (e.g., infrastructure, supply, evidence, communication) and by the local actors to efficiently enact, and if necessary adapt, national guidelines for local execution, in a typical command-and-control manner. But COVID-19 has threatened this equilibrium. Since the beginning, some regions have charged that the central government’s response has been too slow and disjointed and have started organizing the response to coronavirus autonomously.
Each region was differently hit by the virus and tried to implement appropriate and coherent health policy measures. Conversely, central governments tried to impose universal measures in the name of the unity of the nation thus prompting conflicts between the regions and the State first, and between regions afterwards. This happened not only in Italy.
A series of missed chances by the US Federal Government to ensure more widespread testing came during the early days of the outbreak, when containment would have been easier. Even now, after weeks of mounting frustration toward federal agencies over flawed test kits and burdensome rules, states with growing cases such as New York and California are struggling to test widely for the coronavirus. In Germany, the first phase of the emergency has been successfully governed at the Federal level, which promptly facilitated adequate responses in the Landers (regions) based on local needs and contributed to keeping mortality rates at low levels compared to other EU countries. The second phase, however, appears to be problematic, unveiling weaknesses in the capability of the Federal government to coordinate Landers and thus emphasizing asymmetries that are now impacting local economies.
Decentralized governance in managing population health and healthcare can attain excellent performance provided that the central government becomes more rapid in responding, less bureaucratic, streamlines processes and procedures, increases its capability to analyze and interpret future (demographic, epidemiologic, technological) trends so as to anticipate health policies aimed at supporting and coordinating the work of local governments.
More attention on primary care and public health
When epidemics spread, there was no time to re-design care services, so those regions that already routinely used territorial services converted them to manage infected patients. Areas like Scandinavia, the Catalan region of Spain and the Veneto region of Italy had more robust models of primary care and were able to keep patients at home by organizing different forms of remote monitoring, thus alleviating the pressure on hospitals and, at the same time, providing effective care to home-based patients. Furthermore, the Covid-19 experience has shown the importance of effective public health services. Over time, public health services have become disconnected from the gamut of services provided at the single patient level, reducing the level of coordination. Epidemics, as COVID-19 has reminded us, require that community interventions be coordinated with primary care. To move toward community intervention requires reconnecting the public health and hygiene mandate with that aimed at guaranteeing individual patient services through large scale managerial action.
The fast pace of health care services’ transformation
If there is one thing that we have realized, it is that local health systems can be both flexible and controlled, thanks in large part to the ability of top management to improvise within a system full of constraints and in unknown territory. This silent community of professionals (healthcare managers, starting with the general managers) acted by reorienting the organization of LHAs that had become unwieldy (the average population covered by an LHA has climbed to 500,000 inhabitants) due to continued mergers and concentration of processes over the last few years. The hospitals and LHAs were able not only to withstand the onslaught of the virus but also weather the uneasy relationships between the national, regional and local levels. Unprecedented crisis made clear how important effective and capable management at the provider level is for facing these challenges. Boosting management capacity at the local level is one of the essential ingredients of a strong and resilient healthcare system.
Not to forget
When Covid-19 is over, human losses will be painfully countless while economic downturns have already started counting thousands of billions of US dollars worldwide. As strange as it may seem to say, we believe that COVID-19 did not create new problems but violently brought to the surface many of the challenges healthcare systems have been facing for a long time.
Governments play a pivotal role in ruling healthcare systems, and this becomes even truer in times of epidemics, i.e., whenever health clearly reveals its ‘public good’ nature. Healthcare is the cornerstone of society and must be funded appropriately.
The pandemic is evaporating, but the extra funds for the Italian public healthcare system must not. It’s time to develop a forward-looking, evidence-based road-map for making the future normality different from the one before.
by Rosanna Tarricone, Aleksandra Torbica, Valeria D. Tozzi