Questo articolo nasce dal fatto che sempre più spesso mi trovo a parlare del nostro Servizio Sanitario Nazionale con non italiani, ultimamente in particolare con svizzeri. Se da un lato noto spesso stupore quando gli interlocutori scoprono come il nostro Sistema Sanitario Nazionale funziona e cosa offre, dall’altro a mia volta io mi sorprendo del come si possa dichiarare soddisfazione verso sistemi in cui la salute dell’individuo non è considerata un bene che la comunità dovrebbe tutelare. Ho scritto dunque in inglese per raccontare agli stranieri quello che considero un motivo di vanto per l’Italia, E ho raccontato in particolare due dei settori in cui il Servizio Sanitario Nazionale da il meglio di sé, scelti fra quelli nei quali mi è capitato di imbattermi nel mio lavoro di giornalista scientifica.
Traveling in foreign countries, there is one thing I noticed: Italians living abroad usually miss the Italian health system, the so-called Servizio Sanitario Nazionale (National Health Service, SSN).
It might sound hilarious, given that in the homeland complaining about health system seems to be one of the favourite leitmotifs. Indeed this is a typical case in which it seems that you need to put some distance between yourself and something in order to appreciate it.
The National Health Service has been instituted 40 years ago, in 1978, thanks to Tina Anselmi, who was at that time minister of health (the first woman in Italy to hold that office). Since then, the National Health Service has demonstrated to be one of the “Italian excellences”. To understand what makes it special, it is useful to read what it is stated in the law ratifying its establishment.
“The Italian Republic protects health as a fundamental right of the individual and the interest of the community through the National Health Service. The protection of physical and mental health must take place respecting the dignity and freedom of the human being. The National Health Service consists of all the functions, facilities, services and activities for the enhancement, maintenance and recovery of the physical and mental health of the entire population without distinction of individual or social conditions and in accordance with procedures that ensure the equality of citizens towards the service. The implementation of the National Health Service is responsibility of the State, the Regions and Local Territorial Bodies, guaranteeing the participation of citizens.”(La Repubblica tutela la salute come fondamentale diritto dell’individuo e interesse della collettività mediante il servizio sanitario nazionale. La tutela della salute fisica e psichica deve avvenire nel rispetto della dignità e della libertà della persona umana. Il servizio sanitario nazionale è costituito dal complesso delle funzioni, delle strutture, dei servizi e delle attività destinati alla promozione, al mantenimento ed al recupero della salute fisica e psichica di tutta la popolazione senza distinzione di condizioni individuali o sociali e secondo modalità che assicurino l’eguaglianza dei cittadini nei confronti del servizio. L’attuazione del servizio sanitario nazionale compete allo Stato, alle regioni e agli enti locali territoriali, garantendo la partecipazione dei cittadini. L. 23 dicembre 1978, n. 833 (1).)
With these words, the State takes on itself the responsibility of the health of each individual person in Italy. That means, that doesn’t matter how wealthy, young or old he/she might be: from the point of view of the health, everybody in Italy has the right to receive effective medical assistance. It is also important to note, that the individual health is considered to be not only in the interest of the single person but rather of the whole community. This is a very wise concept, given the social cost that each ill-cured person has, in terms of family burden but also loss of productivity and so on.
Of course the system is not perfect at all, and the discussion about how to make it more efficient is old almost as much as the health system itself. One of the main problems are the differences in the quality of the services across Regions, especially moving from north to south. These problems are the starting point of the many complains you can hear in Italy about the Servizio Sanitario Nazionale. But the weak points, although several, should not let us forget how lucky we are to have it.
Being a journalist specialized in Science and Medicine, it is not rare for me to come across amazing examples of its achievements. I’ll report here about two of them: birth assistance and organ transplantations.
One of the moments in which the Italian health System gives its best, is birth. All pregnant women have the right to be assisted in a hospital, including those who are illegal immigrants. And the results are remarkable. One of the most important indicators to understand the quality of infant assistance is the so-called Infant Mortality Rate, expressing the number of deaths of children under one year of age per 1000 live births. According to the more recent Eurostat data, in 2016 in Italy there were 2,8 deaths for 1.000 live births (this kind of data needs time to be collected and analyzed, that’s why usually they pertain to more than one year before). Although of course each single death is a tragedy, overall the result is very good. In comparison, in France there have been recorded 3.7 deaths for 1.000 live births, in Germany 3.4 and in Switzerland 3.6. Better results are scored in Sweden, with 2,2 deaths for 1.000 live births, or in Finland, with 1.9. Unfortunately, the Italian national scores hide internal differences. “Would we separate the data from the south from those from the north of Italy, we would discover that in the north the Infant Mortality Rate is actually comparable with the best scores recorded in North European countries. The average Italian value is already very good, but it would be much better if southern regions were not suffering structural deficits”, explains Mario De Curtis, who is Professor of Paediatrics in the University of Rome, and Director of Neonatology Unit of the general hospital Umberto I in Rome. Very interesting are also the data of the neonatal mortality rate, which is the number of deaths for 1000 live births in the first 28 days of life. According to the UN Inter-agency Group for Child Mortality Estimation for 2017 the rate in Italy is 2 deaths for 1000 live births, the same as in France, Germany, Sweden and Finland, while in Switzerland the rate is 3/1000. “It is important to note that the Italian Health Systems is really aimed at protecting everybody, although of course we try our best to avoid ‘over treatment’. For instance, in case of very pre-term babies, we always evaluate the general conditions of the child, while in other countries there is a threshold of gestational age or birth weight, under which the newborn infant receives only palliative care. Recently we assisted a very pre-term infant, whose North European parents were by chance in Italy. The child would have not received intensive care in his own country, because there his birth age was considered to low. But we gave our best for him, and now he is in good health”, says Mario De Curtis.
Organ Transplantation is another reason to be proud. Starting from 1966, in Italy tens of thousands organ transplantations have been carried on. In the ranking of European countries for number of organ transplantations, Italy’s position is high. According to the Newsletter Transplant 2018 (not yet distributed, but to be published in a short time here ), in 2017 Italy was the third country for number of donors (1.714), following the world leader Spain (2.183), and France (1.933), but preceding United Kingdom (1.492) and Germany (797). In Switzerland deceased donors were 145 in 2017, but of course in this field it is impossible to compare countries with very different sizes (such as Italy and Switzerland) because of a number of reasons, among them because the number of citizens is strongly related with the one of donors. According to the same source, Italy was third for number of liver and heart transplantations, and at the fourth for those of kidney. “The leading position that Italy has in the field of organ transplantation is due to two key elements. First of all, our National Health System being public could effort the huge investments needed in this field: it is quite hard to imagine that an health system based on private investments could do the same, reaching the same targets. The second fundamental element is that people trust the system and this makes the number of donations to rise. Through transparent policies, we have been able to demonstrate that all possible efforts to save the life of a patient are done before he or she is declared death and explantation is taken into account. Moreover, in order to establish the best possible coupling between donor and recipient, we have set up a special unity operating 24 hours a day and trained to analyze every single case”, explains Alessandro Nanni Costa, Director of the National Transplantation Centre.
Last but not least, the costs of the system must be taken into account. Since it is a contributory system financed through taxes, and the service is the same for all, those with higher earning pay more than those who have lower incomes although they receive the same services. To many Italians, this equality in terms of health assistance represents a high expression of democracy. According to the report Oasis 2016, summarized by Sole 24 Ore (the Italian newspaper focused on economy), the expenses for the Italian Health Systems corresponds to about 7% of GDP (in Switzerland, the health costs amount to about 12% of GDP, ). The health costs pro capita in Italy are not high. The total expenditure pro capita, normalized according to the local purchasing power and including private expenses not reimbursed by the SSN, in 2014 was 3.239 dollars in Italy, 3.337 in the United Kingdom, 4.508 in France, 5.182 in Germany, and 9.403 in the USA.
And what is very important to stress, is that the public health system represents a driving force in the Italian economy, encouraging the development of high tech solutions, biotechnology and new drugs. “Health” is the sixth most important economic sector in the country, following manufacturing, but forerunning food and fashion.