Universal Healthcare Cases

**87**

**Chapter 7**

**Abstract**

and Resistance

restricting spending and rights.

**1. Introduction**

right of citizenship.

*Telma Maria Gonçalves Menicucci*

The Brazilian Unified Health

System: Thirty Years of Advances

In 1988, in the context of the re-democratization of Brazil after an authoritarian period, a new Federal Constitution promoted an institutional rupture in the hitherto valid frameworks of health policy, whose origin and expansion until then had been prioritized by the means of insurance restricted to workers inserted in the formal labor market. The constitution has defined principles and guidelines for a reform informed by a publicist perspective and by a conception of health as the right of everyone and the duty of the state, with the corollary of universalization and equality. For this, the unique health system was created. The chapter aims to describe the construction and evolution of the universal health system of Brazil and its results and perspectives. The construction of the universal system from a segmentation legacy, considering the argument that the previous policies defined constraints for the subsequent institutional development, is portrayed. After that, the evolution of the health system and its results and political, financial, and institutional difficulties, also considering the institutional characteristics derived from Brazilian federative institutions, has been discussed. Finally, the country's current political scenario is presented, which points to a new cycle of social policies, including health policy, in the sense of

**Keywords:** health system, Brazil, universalization, right of the citizen

After a long period of more than 20 years of authoritarian military governments, in 1988, as a culmination of the country's re-democratization process, a new Federal Constitution was enacted in Brazil. Through this federal constitution, a new political pact was signed not only for the restoration of the rule of law but for a significant expansion of human rights and citizenship, including social rights. Following a trajectory characterized by the structuring and development of a social protection system predominantly corporate-meritocratic, initiated since the 1930s and excluding vast segments of the population, Brazil was in the right step with the pioneer countries that organized welfare systems more robust. And the constitution laid the groundwork for a significant change in both the form of social intervention of the state and the normative and evaluative principles that guide its actions, pointing to a system of universalist protection based on the concept of the

#### **Chapter 7**

## The Brazilian Unified Health System: Thirty Years of Advances and Resistance

*Telma Maria Gonçalves Menicucci*

#### **Abstract**

In 1988, in the context of the re-democratization of Brazil after an authoritarian period, a new Federal Constitution promoted an institutional rupture in the hitherto valid frameworks of health policy, whose origin and expansion until then had been prioritized by the means of insurance restricted to workers inserted in the formal labor market. The constitution has defined principles and guidelines for a reform informed by a publicist perspective and by a conception of health as the right of everyone and the duty of the state, with the corollary of universalization and equality. For this, the unique health system was created. The chapter aims to describe the construction and evolution of the universal health system of Brazil and its results and perspectives. The construction of the universal system from a segmentation legacy, considering the argument that the previous policies defined constraints for the subsequent institutional development, is portrayed. After that, the evolution of the health system and its results and political, financial, and institutional difficulties, also considering the institutional characteristics derived from Brazilian federative institutions, has been discussed. Finally, the country's current political scenario is presented, which points to a new cycle of social policies, including health policy, in the sense of restricting spending and rights.

**Keywords:** health system, Brazil, universalization, right of the citizen

#### **1. Introduction**

After a long period of more than 20 years of authoritarian military governments, in 1988, as a culmination of the country's re-democratization process, a new Federal Constitution was enacted in Brazil. Through this federal constitution, a new political pact was signed not only for the restoration of the rule of law but for a significant expansion of human rights and citizenship, including social rights. Following a trajectory characterized by the structuring and development of a social protection system predominantly corporate-meritocratic, initiated since the 1930s and excluding vast segments of the population, Brazil was in the right step with the pioneer countries that organized welfare systems more robust. And the constitution laid the groundwork for a significant change in both the form of social intervention of the state and the normative and evaluative principles that guide its actions, pointing to a system of universalist protection based on the concept of the right of citizenship.

Among the constitutional changes, it is worth mentioning the introduction of the concept of social security as a more comprehensive form of protection that expresses the idea of the constitution of a network of protection to the social risks inherent to the life cycle, to the labor trajectory, and to the insufficiency of income. In the Brazilian constitutional definition, security comprises an integrated set of actions aimed at ensuring the rights to health, welfare, and social assistance, based on a set of policies with a universal vocation, in addition to expressing an effort to integrate contributory and noncontributory policies based on a broad and diversified funding base.

Particularly in health, the constitutional provisions promoted an institutional rupture in the hitherto valid frameworks of health policy, particularly in relation to health care, whose origin and expansion until then had been prioritized by the means of insurance restricted to workers inserted in the formal labor market. The constitution, which is very detailed in relation to health policy, has defined principles and guidelines for a reform informed by a publicist perspective and by a conception of health as the right of everyone and the duty of the state, with the corollary of universalization and equality. In the 1990s, the process of implementing legal-institutional changes defined in the constitution began, which involved drastic changes in the organization and breadth of the health system. The implementation process was tortuous and conflicting, initially marked by a political, economic, and ideological context, both national and international, not conducive to expansion of spending and state action. However, despite resistance and obstacles, the health policy designed in the constitution was institutionalized, and a universal health system was implemented, with significant results in relation to access, although it is greatly affected by the diverse political and economic conjunctures in which this process has if given, in addition to suffering the feedback effects of previous policies that worked to build a dual system, made up of a public and a private segment.

The recent period, whose results are not yet defined, seems to signal a new cycle of Brazilian social policies in the opposite direction of the Federal Constitution of 1988, in a context of broad political re-articulation and conservative nuance. A broader process of institutional change is under way that signals the reduction of social policies in a context of strong fiscal adjustment and market valuation, in which policies move away from a constitutional normative idea—rights to be guaranteed by the state—and pass to be seen as costs to be reduced due to a supposed exhaustion of funding capacity.

This chapter aims to describe in an analytical way the construction and evolution of the universal health system of Brazil and its results and perspectives. With these objectives, the next section portrays the construction of the system from a segmentation legacy, considering the argument that the previous policies shaped a certain trajectory and defined constraints for the subsequent institutional development, forging, in fact, a dual system, though formally universal. Section 3 discusses the evolution of the health system and its results and political, financial, and institutional difficulties, adding to the analysis the institutional characteristics derived from the format of the Brazilian federative institutions. Finally, Section 4 aligned some conclusions and points out the trends currently that endanger the Brazilian health system.

#### **2. The construction of the universal health system**

Assistance to individual health as a public policy was developed in Brazil incorporated into social security benefits and until the Federal Constitution of 1988 was primarily a benefit linked to the formal work contract, not constituting a public benefit to which the entire population is entitled. Another expression of

**89**

country's hospital beds [3].

*The Brazilian Unified Health System: Thirty Years of Advances and Resistance*

this insurance perspective is the dichotomization that was established in health policy until the end of the 1980s, expressed in a functional and institutional differentiation. The Ministry of Health was responsible for the actions of a collective nature in the form of health campaigns and some basic assistance actions of restricted scope. Social Security, in the various institutional formats that it assumed throughout its trajectory, was the responsibility of individual health care, restricted to the insured and their dependents, which left rural workers and those without a formal employment relationship unprotected. The "regulated citizenship," a conception that expresses the relation between occupation and citizenship, was in force in Brazil, which recognized certain social rights to sectors of urban salaried workers [1]. Among these rights, health care is included, even if secondary

It was only in the 1960s that there was a substantial expansion of social security health care. This expansion took place largely, particularly in the case of hospital care, through the purchase of services, using the private service network, which developed independently in the public sector [2]. From the 1970s, there was a stagnation in the relative capacity of the public hospital network that remained practically unchanged until the 1990s, which had as counterpart the growth of the

. In addition to the purchase of services, another form of articulation between Social Security and the private sector was through the establishment of agreements with companies under which, through a subsidy, the company would assume responsibility for medical care for its employees. In most cases, instead of directly providing the medical services, the company purchased the services of another specialized company, called "group medicine," "medical company," or "medical groups," establishing a triangular agreement between the social security, employer, and medical company. The practice of this covenant favored the expansion of group medicine, restricted to the areas of great concentration of large employer compa-

nies, usually located in the more developed regions of the country [4].

Gradually, this form of private health assistance is taking up more space than public assistance in large enterprises on the south/southeast axis—the most developed region of the country—and will be the pillar of the supplementary assistance

New forms of inequalities between different strata of workers are introduced in this form of medical care. In general, the agreements were established with large companies, with more specialized labor and higher wages. Medical groups also tend to focus on the more industrialized and urbanized regions. As a consequence, during the 1960s and 1970s, service differentiation would not occur between professional categories but between professional qualifications [5]. Encouraged and legitimized by the public initiative of the agreements, the eminently private forms of health care thereafter developed, which included a great diversity of possibilities of alternative plans and contracts. The different forms of differentiation recreated the particularistic demands of another nature, this time linked to the employment

The counterpart of the option to purchase private health services was the low development of state capacity, mainly for the production of hospital services, which made the public power dependent on the private sector for the expansion of health care. At the same time, the regulatory capacity of the state has not developed, which was strongly captured by private interests. This situation will translate into the prominence of private interests over collective ones, as well as the increase

<sup>1</sup> As of the mid-1970s, the number of private hospital beds already corresponded to more than 70% of the

*DOI: http://dx.doi.org/10.5772/intechopen.86834*

importance of the private hospital network1

that will be developed in the following decades.

contract and no longer to the professional category.

to social security benefits.

#### *The Brazilian Unified Health System: Thirty Years of Advances and Resistance DOI: http://dx.doi.org/10.5772/intechopen.86834*

this insurance perspective is the dichotomization that was established in health policy until the end of the 1980s, expressed in a functional and institutional differentiation. The Ministry of Health was responsible for the actions of a collective nature in the form of health campaigns and some basic assistance actions of restricted scope. Social Security, in the various institutional formats that it assumed throughout its trajectory, was the responsibility of individual health care, restricted to the insured and their dependents, which left rural workers and those without a formal employment relationship unprotected. The "regulated citizenship," a conception that expresses the relation between occupation and citizenship, was in force in Brazil, which recognized certain social rights to sectors of urban salaried workers [1]. Among these rights, health care is included, even if secondary to social security benefits.

It was only in the 1960s that there was a substantial expansion of social security health care. This expansion took place largely, particularly in the case of hospital care, through the purchase of services, using the private service network, which developed independently in the public sector [2]. From the 1970s, there was a stagnation in the relative capacity of the public hospital network that remained practically unchanged until the 1990s, which had as counterpart the growth of the importance of the private hospital network1 .

In addition to the purchase of services, another form of articulation between Social Security and the private sector was through the establishment of agreements with companies under which, through a subsidy, the company would assume responsibility for medical care for its employees. In most cases, instead of directly providing the medical services, the company purchased the services of another specialized company, called "group medicine," "medical company," or "medical groups," establishing a triangular agreement between the social security, employer, and medical company. The practice of this covenant favored the expansion of group medicine, restricted to the areas of great concentration of large employer companies, usually located in the more developed regions of the country [4].

Gradually, this form of private health assistance is taking up more space than public assistance in large enterprises on the south/southeast axis—the most developed region of the country—and will be the pillar of the supplementary assistance that will be developed in the following decades.

New forms of inequalities between different strata of workers are introduced in this form of medical care. In general, the agreements were established with large companies, with more specialized labor and higher wages. Medical groups also tend to focus on the more industrialized and urbanized regions. As a consequence, during the 1960s and 1970s, service differentiation would not occur between professional categories but between professional qualifications [5]. Encouraged and legitimized by the public initiative of the agreements, the eminently private forms of health care thereafter developed, which included a great diversity of possibilities of alternative plans and contracts. The different forms of differentiation recreated the particularistic demands of another nature, this time linked to the employment contract and no longer to the professional category.

The counterpart of the option to purchase private health services was the low development of state capacity, mainly for the production of hospital services, which made the public power dependent on the private sector for the expansion of health care. At the same time, the regulatory capacity of the state has not developed, which was strongly captured by private interests. This situation will translate into the prominence of private interests over collective ones, as well as the increase

*Universal Health Coverage*

exhaustion of funding capacity.

Brazilian health system.

**2. The construction of the universal health system**

Among the constitutional changes, it is worth mentioning the introduction of the concept of social security as a more comprehensive form of protection that expresses the idea of the constitution of a network of protection to the social risks inherent to the life cycle, to the labor trajectory, and to the insufficiency of income. In the Brazilian constitutional definition, security comprises an integrated set of actions aimed at ensuring the rights to health, welfare, and social assistance, based on a set of policies with a universal vocation, in addition to expressing an effort to integrate contributory

Particularly in health, the constitutional provisions promoted an institutional rupture in the hitherto valid frameworks of health policy, particularly in relation to health care, whose origin and expansion until then had been prioritized by the means of insurance restricted to workers inserted in the formal labor market. The constitution, which is very detailed in relation to health policy, has defined principles and guidelines for a reform informed by a publicist perspective and by a conception of health as the right of everyone and the duty of the state, with the corollary of universalization and equality. In the 1990s, the process of implementing legal-institutional changes defined in the constitution began, which involved drastic changes in the organization and breadth of the health system. The implementation process was tortuous and conflicting, initially marked by a political, economic, and ideological context, both national and international, not conducive to expansion of spending and state action. However, despite resistance and obstacles, the health policy designed in the constitution was institutionalized, and a universal health system was implemented, with significant results in relation to access, although it is greatly affected by the diverse political and economic conjunctures in which this process has if given, in addition to suffering the feedback effects of previous policies that worked to build a dual system, made up of a public and a private segment.

The recent period, whose results are not yet defined, seems to signal a new cycle

This chapter aims to describe in an analytical way the construction and evolution of the universal health system of Brazil and its results and perspectives. With these objectives, the next section portrays the construction of the system from a segmentation legacy, considering the argument that the previous policies shaped a certain trajectory and defined constraints for the subsequent institutional development, forging, in fact, a dual system, though formally universal. Section 3 discusses the evolution of the health system and its results and political, financial, and institutional difficulties, adding to the analysis the institutional characteristics derived from the format of the Brazilian federative institutions. Finally, Section 4 aligned some conclusions and points out the trends currently that endanger the

Assistance to individual health as a public policy was developed in Brazil incorporated into social security benefits and until the Federal Constitution of 1988 was primarily a benefit linked to the formal work contract, not constituting a public benefit to which the entire population is entitled. Another expression of

of Brazilian social policies in the opposite direction of the Federal Constitution of 1988, in a context of broad political re-articulation and conservative nuance. A broader process of institutional change is under way that signals the reduction of social policies in a context of strong fiscal adjustment and market valuation, in which policies move away from a constitutional normative idea—rights to be guaranteed by the state—and pass to be seen as costs to be reduced due to a supposed

and noncontributory policies based on a broad and diversified funding base.

**88**

<sup>1</sup> As of the mid-1970s, the number of private hospital beds already corresponded to more than 70% of the country's hospital beds [3].

of the expenses of medical care to levels that would end up compromising the governmental financing capacity of the assistance [4].

A legal instrument, established in the 1980s and in force until today, was the tax waiver that started to function as an indirect state incentive for companies to maintain health plans for their employees. As a result, companies obtained legal permission to pass on their employees' health expenses to product prices, computing health-care expenses as operating costs which is therefore subject to deduction of gross income for the purposes of income tax. Through this indirect incentive, the public decision contributed to the expansion of private health care within companies, already properly structured for this since the 1960s and 1970s, when they had direct incentives.

The same incentive was given to the individual option for private health insurance. The tax policy began to allow deductions of the taxable income of the individuals for the purpose of payment of the income tax and, in this way, contributed to the insertion in the private health insurance or even for the use of the liberal medicine (direct disbursement) of people from the highest income strata. From the point of view of the legitimization of public services, the tax break further weakens the public sector, by favoring the exclusion of its coverage from citizens with greater purchasing power, whose behavior, indirectly, is stimulated by tax policy.

In the 1980s, private assistance ceased to be complementary and became supplementary, becoming autonomous in terms of both funding and how to attract clients. There is a significant expansion of the private forms of health care, both by expanding coverage of business health insurances for service sector workers and of the south/southeast axis and by the autonomous commercialization of health plans due to the migration of clients who paid directly service providers for health insurances as a result of aggressive strategies to expand health insurance markets [6, 7]. By the end of the decade, the private sector was consolidated and quite vigorous.

The worsening of the social security financial crisis in the 1980s marked a moment of inflection, with the emergence of proposals for alternative policies for the health system that emphasized the reversal of the model that privileged private service providers through the channeling of social security resources to the public sector. More or more important than the financial crisis of welfare and the incapacity to sustain this model is the coincidence of the crisis with the process of democratization of the country, which puts on the scene other political actors. In a context of political struggle between alternative health policy projects, it will be possible to change the configuration of the medical assistance model, within the scope, however, of the constraints arising from the institutional configuration of health policy them in force, and whose main features were:


**91**

tion and recovery.

in the area of health" ([9], p. 41).

*The Brazilian Unified Health System: Thirty Years of Advances and Resistance*

the businessmen of the sector, are the beneficiaries of private health insurances, particularly the employees of the companies and public institutions that administer or contract health insurances. By having access to differentiated

In the midst of the country's democratization process, significant changes were

, which developed since the mid-1970s, in the context of the authoritar-

assistance, they become their supporters, explicitly or implicitly.

enshrined in the new constitution enacted in 1988. The health reform was the result of a broad and victorious political-ideological movement, called the sanitary

ian regime and the struggle for the re-democratization of the country. Opposition to the military regime included the struggle to broaden social policies and redefine them toward universal benefits. The discussion of the "democratization of health" was made more intensely via the "sanitary movement," which achieved a high degree of organicity and great political visibility, and played a relevant role in the

The formation of the health policy reform proposal involved the theoretical construction of a model of understanding the social determinants of health and a set of strategic actions aimed at the dissemination of ideas, the articulation of people and organizations, and the occupation of institutional spaces for experimentation of innovative projects as a mechanism to constitute an alternative to the current policy. Of academic origin, the health reform movement managed to articulate a diverse set of actors, such as the medical category, the "popular health movement," bureaucratic segments, and the municipalist movement, made up of the secretaries and municipal health technicians. One of the political strategies was, on the one hand, to act in the parliament as a place for public debate on health and the organization of the movement and, on the other hand, the involvement with elections of deputies, mayors, and councilors who had health on their electoral platforms and were linked to the more general issue of democratization [8]. In the context of dissatisfaction with the authoritarian regime and in the movement to establish a new pact in the country, it was possible to overcome sectoral or corporate goals and interests in affirming an alternative to the health sector, whose main content was universalization and public

responsibility, as opposed to the current segmented and hybrid model.

The new constitutional charter indicated a broad reform in current policy, both in its normative principles and in its organizational format, which significantly altered the previous pattern by breaking with the meritocratic character of health care and incorporating it into the idea of right of citizenship, besides breaking with the previous dichotomization between actions of a collective nature and individual actions. This right to health was defined in the constitution comprehensively as follows: Article 196. Health is the right of all and the duty of the State, guaranteed by social and economic policies aimed at reducing the risk of disease and other damage and universal and equal access to actions and services for their promotion, protec-

This definition includes two dimensions. Firstly, the understanding of the social determination of health, indicating that social and economic policies should contribute in reducing the risks of becoming ill, so that the right to health is not limited to access to health services but supposes that all must have the opportunity or appropriate conditions to reach their health potential. Secondly, the definition indicates a public policy guideline for guaranteeing health actions and services,

<sup>2</sup> According to Gerschman, the so-called "sanitary movement" was "a narrow group of intellectuals, physicians and political leaders of the health sector, mostly from the Brazilian Communist Party (PCB), who played a prominent role in opposition to the military regime, as well as a specific political trajectory

*DOI: http://dx.doi.org/10.5772/intechopen.86834*

movement2

reformulation of health policy.

the businessmen of the sector, are the beneficiaries of private health insurances, particularly the employees of the companies and public institutions that administer or contract health insurances. By having access to differentiated assistance, they become their supporters, explicitly or implicitly.

In the midst of the country's democratization process, significant changes were enshrined in the new constitution enacted in 1988. The health reform was the result of a broad and victorious political-ideological movement, called the sanitary movement2 , which developed since the mid-1970s, in the context of the authoritarian regime and the struggle for the re-democratization of the country. Opposition to the military regime included the struggle to broaden social policies and redefine them toward universal benefits. The discussion of the "democratization of health" was made more intensely via the "sanitary movement," which achieved a high degree of organicity and great political visibility, and played a relevant role in the reformulation of health policy.

The formation of the health policy reform proposal involved the theoretical construction of a model of understanding the social determinants of health and a set of strategic actions aimed at the dissemination of ideas, the articulation of people and organizations, and the occupation of institutional spaces for experimentation of innovative projects as a mechanism to constitute an alternative to the current policy. Of academic origin, the health reform movement managed to articulate a diverse set of actors, such as the medical category, the "popular health movement," bureaucratic segments, and the municipalist movement, made up of the secretaries and municipal health technicians. One of the political strategies was, on the one hand, to act in the parliament as a place for public debate on health and the organization of the movement and, on the other hand, the involvement with elections of deputies, mayors, and councilors who had health on their electoral platforms and were linked to the more general issue of democratization [8]. In the context of dissatisfaction with the authoritarian regime and in the movement to establish a new pact in the country, it was possible to overcome sectoral or corporate goals and interests in affirming an alternative to the health sector, whose main content was universalization and public responsibility, as opposed to the current segmented and hybrid model.

The new constitutional charter indicated a broad reform in current policy, both in its normative principles and in its organizational format, which significantly altered the previous pattern by breaking with the meritocratic character of health care and incorporating it into the idea of right of citizenship, besides breaking with the previous dichotomization between actions of a collective nature and individual actions. This right to health was defined in the constitution comprehensively as follows:

Article 196. Health is the right of all and the duty of the State, guaranteed by social and economic policies aimed at reducing the risk of disease and other damage and universal and equal access to actions and services for their promotion, protection and recovery.

This definition includes two dimensions. Firstly, the understanding of the social determination of health, indicating that social and economic policies should contribute in reducing the risks of becoming ill, so that the right to health is not limited to access to health services but supposes that all must have the opportunity or appropriate conditions to reach their health potential. Secondly, the definition indicates a public policy guideline for guaranteeing health actions and services,

*Universal Health Coverage*

of the expenses of medical care to levels that would end up compromising the

A legal instrument, established in the 1980s and in force until today, was the tax waiver that started to function as an indirect state incentive for companies to maintain health plans for their employees. As a result, companies obtained legal permission to pass on their employees' health expenses to product prices, computing health-care expenses as operating costs which is therefore subject to deduction of gross income for the purposes of income tax. Through this indirect incentive, the public decision contributed to the expansion of private health care within companies, already properly structured for this since the 1960s and 1970s, when they had direct incentives.

The same incentive was given to the individual option for private health insurance. The tax policy began to allow deductions of the taxable income of the individuals for the purpose of payment of the income tax and, in this way, contributed to the insertion in the private health insurance or even for the use of the liberal medicine (direct disbursement) of people from the highest income strata. From the point of view of the legitimization of public services, the tax break further weakens the public sector, by favoring the exclusion of its coverage from citizens with greater

purchasing power, whose behavior, indirectly, is stimulated by tax policy. In the 1980s, private assistance ceased to be complementary and became supplementary, becoming autonomous in terms of both funding and how to attract clients. There is a significant expansion of the private forms of health care, both by expanding coverage of business health insurances for service sector workers and of the south/southeast axis and by the autonomous commercialization of health plans due to the migration of clients who paid directly service providers for health insurances as a result of aggressive strategies to expand health insurance markets [6, 7]. By the end of the decade, the private sector was consolidated and quite vigorous. The worsening of the social security financial crisis in the 1980s marked a moment of inflection, with the emergence of proposals for alternative policies for the health system that emphasized the reversal of the model that privileged private service providers through the channeling of social security resources to the public sector. More or more important than the financial crisis of welfare and the incapacity to sustain this model is the coincidence of the crisis with the process of democratization of the country, which puts on the scene other political actors. In a context of political struggle between alternative health policy projects, it will be possible to change the configuration of the medical assistance model, within the scope, however, of the constraints arising from the institutional configuration of

health policy them in force, and whose main features were:

capacity, both the provider and regulator.

managed by the employer).

a. The principle of regulated citizenship: health care as a work-related benefit, not as a project of universal and equal inclusion. Parallel to the growth of public health care in a universal sense, the segmentation is recreated through the insertion of some workers in private forms of coverage, favored by public incentives.

b.The option to purchase private services: public assistance is developed through the expansion of the private service network and the atrophy of governmental

medical cooperatives, health insurer, and self-management systems (assistance

c.The development of a set of private institutions such as group medicine,

d.As one of its consequences, this policy has led to the constitution of a set of institutions and actors and interests. Among the interests constituted, besides

governmental financing capacity of the assistance [4].

**90**

<sup>2</sup> According to Gerschman, the so-called "sanitary movement" was "a narrow group of intellectuals, physicians and political leaders of the health sector, mostly from the Brazilian Communist Party (PCB), who played a prominent role in opposition to the military regime, as well as a specific political trajectory in the area of health" ([9], p. 41).

guaranteeing universal and equal access to them, expressing a criterion of universal and equal justice in the relationship between the state and citizens.

The focus on the process of implementing the constitutional reform will be equal access to actions and services. In order to give materiality to health policy, the Unified Health System (SUS) was established, defined as the set of public health actions and services provided by federal, state, and municipal public bodies and institutions, since Brazil is a federal state formed by three federative entities with administrative, political, and financial autonomy: the Union, the states (in number of 26), and the municipalities (in number of 5570), besides the federal district constituted by the capital of the country.

The SUS has the following principles: universality of access and gratuity at all levels of health care; equality in care, without any preconceptions or privileges of any kind; the integrality of care, which involves an articulated and continuous set of preventive and curative actions and services, individual and collective; community participation in the process of formulating guidelines and priorities for health policy (by means of health conferences) and in the control and evaluation of actions and services implemented (by means of health councils) at all levels of government; and the political-administrative decentralization, with emphasis on the decentralization of services to the municipalities and the regionalization and hierarchization of the service network.

The SUS funding, defined by the Federal Constitution (FC) of 1988 and amended by the constitutional amendment (CE) in 2000, was defined as the competence of the three federal entities that make up the Brazilian tripartite federation, through resources from its budgets, in addition to including social contributions3 .

As a precursor among developing countries, Brazil was thus establishing, at least from the formal point of view, at the end of the 1990s, a public system of universal coverage defined as an obligation of the Brazilian state. Thus, it preceded what was defined in the WHO Resolution 67/81 on December 12, 2012, which reaffirmed "the right of every human being to the enjoyment of the highest attainable standard of physical and mental health, without distinction as to race, religion, political belief, economic or social condition, and the right of everyone to a standard of living adequate for the health and well-being of oneself and one's family" and recognized "the responsibility of Governments to urgently and significantly scale up efforts to accelerate the transition towards universal access to affordable and quality healthcare services" [10] and to ensure that all people obtain the health services they need without suffering financial hardship when paying for them.

However, the reform of health policy in the late 1980s, which established the universal and public system, failed to incorporate all citizens into free public health care, since some of them were already tied to private forms of assistance. In the constituent process, two opposing visions of health care, defined as "statistic" and "privatizing," were made explicit. If the former represented the innovative perspective of the actors that articulated around the reform, the second represented the interests and conceptions forged in the health policy trajectory as feedback effect of the system in force for more than two decades. Only proponents of the ideas of the health movement had more elaborate proposals, the result of a long process of theoretical development and political articulation. The movement was able to use its knowledge as a power resource in the decision-making process and in the definition of alternatives, making its main proposals reinforced by different categories such as the Central Única dos Trabalhadores (Central Office of Workers), trade

**93**

*The Brazilian Unified Health System: Thirty Years of Advances and Resistance*

established arrangements related to private health care [4].

unions of health professionals, and the Council Federal of Medicine, besides part of the members of the constituent assembly. However, the possibility of an abrupt change in the health system based on the universal and public proposal provoked the mobilization and demonstrated the weight and articulation capacity of both representatives of private institutions (group medicine, medical cooperatives, and insurance companies) and private services providers, united in the defense of the pluralism of the forms of health care and of the "freedom of choice." These actors have demonstrated significant veto power, and, although they have not been able to overcome the most significant institutional changes, particularly the creation of a public system of universal access, they have ensured the preservation of previously

The constitutional text reflected the agreements between these different actors,

and its ambiguities reflect the adjustment between innovative alternatives and consolidated standards. The result was the juridical-legal conformation of a hybrid and segmented system that, while, on the one hand, consecrates health as a right, guarantees universality of access to health care, increases state responsibility, and defines the constitution of an inclusive system, on the other hand, preserves market freedom and ensures the continuity of private forms of care, regardless of any

The change was made possible by an exceptional situation of building a new

The choices defined in the constitution ensured the continuity of the reform with some degree of continuity, in a process of innovation pressed by interests and objectives that had been constituted as a result of previous policies, which limited the possibility of discontinuous changes but at the same time expressed institutional dynamism when defining a reorganization of the public health system.

In the 1990s, the implementation of health reform began, which included, among other things, the transition from a system that was restricted to salaried workers to a universal system; the decentralization of management to autonomous government units from the political-administrative point of view, replacing a highly centralized model; the unification of previously separated structures and activities (collective actions and individual assistance); the expansion of supply and the reorganization of

**3. Implementation and evolution of the health system**

social pact in the process of democratization and in a situation favorable to institutional imbalances, within the framework of which a new legal framework for health was constituted. Within this framework, it was possible to modify the sectoral political arena with the incorporation of new actors who had alternative proposals, which were confronted with those constituted from previous policies. The public health-care crisis, which translated into widespread dissatisfaction, was another factor that favored institutional change, insofar as the health movement knew how to present an alternative to the crisis, place it on the agenda, and obtain political support for it. In this process, an epistemic community was constituted, whose influence was translated into changes in the political process, because it was able to mediate between the crisis and the choices made and to provide a consistent and widely supported proposal. In the democratic transition, a "political window" was opened, so that the problems of the current policy, associated with the broader political process of democratization, converged in such a way as to allow non-hegemonic political forces to decisively influence the formulation of health policy, giving rise, at a specific moment, to the emergence of a policy informed by a publicist ideology and by a conception of health as a right, having as corollary

*DOI: http://dx.doi.org/10.5772/intechopen.86834*

governmental intervention.

universalization and equality.

<sup>3</sup> Social contributions in Brazil refer to a specific type of tax destined exclusively for the costing of social security, some of them for social insure costs and others for noncontributory welfare benefits (health and social assistance).

#### *The Brazilian Unified Health System: Thirty Years of Advances and Resistance DOI: http://dx.doi.org/10.5772/intechopen.86834*

unions of health professionals, and the Council Federal of Medicine, besides part of the members of the constituent assembly. However, the possibility of an abrupt change in the health system based on the universal and public proposal provoked the mobilization and demonstrated the weight and articulation capacity of both representatives of private institutions (group medicine, medical cooperatives, and insurance companies) and private services providers, united in the defense of the pluralism of the forms of health care and of the "freedom of choice." These actors have demonstrated significant veto power, and, although they have not been able to overcome the most significant institutional changes, particularly the creation of a public system of universal access, they have ensured the preservation of previously established arrangements related to private health care [4].

The constitutional text reflected the agreements between these different actors, and its ambiguities reflect the adjustment between innovative alternatives and consolidated standards. The result was the juridical-legal conformation of a hybrid and segmented system that, while, on the one hand, consecrates health as a right, guarantees universality of access to health care, increases state responsibility, and defines the constitution of an inclusive system, on the other hand, preserves market freedom and ensures the continuity of private forms of care, regardless of any governmental intervention.

The change was made possible by an exceptional situation of building a new social pact in the process of democratization and in a situation favorable to institutional imbalances, within the framework of which a new legal framework for health was constituted. Within this framework, it was possible to modify the sectoral political arena with the incorporation of new actors who had alternative proposals, which were confronted with those constituted from previous policies. The public health-care crisis, which translated into widespread dissatisfaction, was another factor that favored institutional change, insofar as the health movement knew how to present an alternative to the crisis, place it on the agenda, and obtain political support for it. In this process, an epistemic community was constituted, whose influence was translated into changes in the political process, because it was able to mediate between the crisis and the choices made and to provide a consistent and widely supported proposal. In the democratic transition, a "political window" was opened, so that the problems of the current policy, associated with the broader political process of democratization, converged in such a way as to allow non-hegemonic political forces to decisively influence the formulation of health policy, giving rise, at a specific moment, to the emergence of a policy informed by a publicist ideology and by a conception of health as a right, having as corollary universalization and equality.

The choices defined in the constitution ensured the continuity of the reform with some degree of continuity, in a process of innovation pressed by interests and objectives that had been constituted as a result of previous policies, which limited the possibility of discontinuous changes but at the same time expressed institutional dynamism when defining a reorganization of the public health system.

#### **3. Implementation and evolution of the health system**

In the 1990s, the implementation of health reform began, which included, among other things, the transition from a system that was restricted to salaried workers to a universal system; the decentralization of management to autonomous government units from the political-administrative point of view, replacing a highly centralized model; the unification of previously separated structures and activities (collective actions and individual assistance); the expansion of supply and the reorganization of

*Universal Health Coverage*

constituted by the capital of the country.

hierarchization of the service network.

guaranteeing universal and equal access to them, expressing a criterion of universal

The focus on the process of implementing the constitutional reform will be equal access to actions and services. In order to give materiality to health policy, the Unified Health System (SUS) was established, defined as the set of public health actions and services provided by federal, state, and municipal public bodies and institutions, since Brazil is a federal state formed by three federative entities with administrative, political, and financial autonomy: the Union, the states (in number of 26), and the municipalities (in number of 5570), besides the federal district

The SUS has the following principles: universality of access and gratuity at all levels of health care; equality in care, without any preconceptions or privileges of any kind; the integrality of care, which involves an articulated and continuous set of preventive and curative actions and services, individual and collective; community participation in the process of formulating guidelines and priorities for health policy (by means of health conferences) and in the control and evaluation of actions and services implemented (by means of health councils) at all levels of government; and the political-administrative decentralization, with emphasis on the decentralization of services to the municipalities and the regionalization and

The SUS funding, defined by the Federal Constitution (FC) of 1988 and amended by the constitutional amendment (CE) in 2000, was defined as the competence of the three federal entities that make up the Brazilian tripartite federation, through resources from its budgets, in addition to including social contributions3

without suffering financial hardship when paying for them.

As a precursor among developing countries, Brazil was thus establishing, at least from the formal point of view, at the end of the 1990s, a public system of universal coverage defined as an obligation of the Brazilian state. Thus, it preceded what was defined in the WHO Resolution 67/81 on December 12, 2012, which reaffirmed "the right of every human being to the enjoyment of the highest attainable standard of physical and mental health, without distinction as to race, religion, political belief, economic or social condition, and the right of everyone to a standard of living adequate for the health and well-being of oneself and one's family" and recognized "the responsibility of Governments to urgently and significantly scale up efforts to accelerate the transition towards universal access to affordable and quality healthcare services" [10] and to ensure that all people obtain the health services they need

However, the reform of health policy in the late 1980s, which established the universal and public system, failed to incorporate all citizens into free public health care, since some of them were already tied to private forms of assistance. In the constituent process, two opposing visions of health care, defined as "statistic" and "privatizing," were made explicit. If the former represented the innovative perspective of the actors that articulated around the reform, the second represented the interests and conceptions forged in the health policy trajectory as feedback effect of the system in force for more than two decades. Only proponents of the ideas of the health movement had more elaborate proposals, the result of a long process of theoretical development and political articulation. The movement was able to use its knowledge as a power resource in the decision-making process and in the definition of alternatives, making its main proposals reinforced by different categories such as the Central Única dos Trabalhadores (Central Office of Workers), trade

<sup>3</sup> Social contributions in Brazil refer to a specific type of tax destined exclusively for the costing of social security, some of them for social insure costs and others for noncontributory welfare benefits (health

.

and equal justice in the relationship between the state and citizens.

**92**

and social assistance).

the health-care model; and the introduction of new management mechanisms that include the participation of society after a long period of restrictions on freedom. This was a major challenge especially for a country with more than 5000 municipalities and deep inequalities between them, both in the capacity to provide services and in socioeconomic conditions and in the health situation and needs [11].

The political conditions for implementing the reform were not very favorable. These include the national and international context marked by the reordering of the role of the state and the state-market relationship in favor of the second and of restriction to universalist policies; the conservative configuration of government coalitions that succeeded the period of democratic transition, in tune with the international environment, which prioritized the processes of adjustment and economic stabilization, accompanied by structural reforms, in the opposite direction to the expansion of government functions and rights enshrined in the constitution; the fragmentation of the health movement and the idealizer of the reform, from the process of democratization, when its heterogeneities and party cleavages were evidenced; the absence of organized support from the main beneficiaries of the SUS, located in the lower social strata; and the fragile and contradictory support of the organized segment of the workers, the majority covered by private health ensures and who did not have immediate interests in a universal system and usually included in their labor agenda the supply of these ensures.

Given the redistributive character of the health reform, broader coalitions would be necessary for its effectiveness, which proved to be very difficult given the political composition of the health arena constituted by different actors and interests configured throughout the health trajectory, as providers of private services, various modalities of health insurance operators, users of private health insurance, etc.

To reach the ultimate goals of the reform, financing was an indispensable resource, involving not only the volume but also the way federal resources were transferred to states and municipalities, since decentralization was made dependent on federal resources. There is a great consensus among analysts and managers in Brazil that financing has been the greatest obstacle to the implementation of the constitutional right to health, but politically the process of its definition has been conflicting, in contexts of restrictive spending policies and lack of definition of sources of financing. After a period of great instability in funding and as a result of pressure from the defense coalition of the SUS, Constitutional Amendment No. 29 was approved in 2000. This amendment defined minimum resources for the financing of public health actions and services in the form of linking budgetary resources of the states and municipalities to health (12 and 15% of their revenues, respectively), and although it established fewer binding rules for the Union, it linked its spending to GDP growth.

Contradictory, in 1998, while discussing the linking of resources to the SUS, the Law 9665 was approved, which regulated private health insurance and plans, and indicated the government's interest in leveraging the growth of the private market. This regulation formalized the duality of the Brazilian health system and politically weakened the proposal of a universal system, although the regulatory process was made independently of national health policy and without even denying or officially redirecting it.

The application of CE 29 has in fact established a sharing between federated entities of health spending and allowed for greater stability in financing, in addition to continuous resource growth, particularly by increasing the expenditures of subnational entities, with a progressive relative decrease in the participation of the Union in the costing of the SUS, although it is still much higher than the expenses of other federated entities (**Table 1**):

**95**

outpatient care [15].

*The Brazilian Unified Health System: Thirty Years of Advances and Resistance*

However, there is a consensus that resources are insufficient to finance a universal system. In addition to spending relatively little on health (only 6.8% of total public spending and 3.8% of GDP), public health expenditure was US\$439.61 in 2014, corresponding to only 46.4% of total spending in health [14]. Pressures for the expansion of resources destined to SUS permeate the history of the sector. A positive response from the National Congress in this regard was the approval of Law 12,858/2013, which included health in the sharing of resources derived from oil royalties, in a context in which the country celebrated the discovery of oil reserves in the pre-salt layer.

Municipalities 21.7 28.5 31.1 States 18.6 26.4 25.7 Union 59.8 45.1 43.2

**2000 2010 2017**

Even within a framework of underfunding considering the characteristic of the universality and integrality of the right to health in Brazil, relevant efforts have been made since the 1990s to make these principles a reality. There was, in fact, the implementation of a universal system with a certain standardization of health policy in a country of continental dimensions. This was favored by federal coordination exercised by the federal government, particularly in the form of incentives and regulation of financial transfers, as well as in the form of federative pacts. The SUS is responsible for the vast majority of health services provided in the country and for the total coverage of approximately 75% of the population, since approximately one quarter of it is a beneficiary of private health insurance. In addition, it serves the total population for certain procedures—cases in which the situation of double coverage of citizens with private coverage is characterized since they do not fail to justify universal public service. These procedures include emergency and emergency care, the use of the Mobile Emergency Care Service (SAMU), blood transfusion, transplants, vaccination programs, some high-cost procedures, and, of course, all actions of a collective nature that affect the population as a whole, such as sanitary and epidemiological surveillance. For example, in 2018, the SUS financed more than 11 million hospitalizations and performed more than 3 billion

One of the SUS's guidelines is integral care, with priority for preventive activities. Since the 1990s it has been sought to reorganize the care model, seeking to revert the logic of emergency care, generally focused on hospital care, which had characterized health care until then, but with high cost and low effectiveness. To that end, policies and actions were defined, along with financial incentives from the

SUS is present throughout the Brazilian territory, including isolated indigenous villages and rural settlements, even with regional and local variations due to diverse financial capacity. The distributive and regulatory role of the federal government is fundamental to allow more homogeneity of assistance. The Brazilian public health system is conceived as a federative pact between three government entities and, based on their articulation and cooperation, aims to guarantee the universality and integrality of health care throughout Brazil. Although there is a sharing of functions, the central government concentrates the authority on decision-making process and in the policy regulation, while subnational governments, particularly municipalities, as federated entities with political autonomy, are responsible for

Union to strengthen primary health care more strongly in the 2000s.

*DOI: http://dx.doi.org/10.5772/intechopen.86834*

*Sources: SIOPS/MS [12]; Piola et al., 2018 [13].*

*Public expenditure on health care by government sphere (%).*

**Table 1.**


#### *The Brazilian Unified Health System: Thirty Years of Advances and Resistance DOI: http://dx.doi.org/10.5772/intechopen.86834*

#### **Table 1.**

*Universal Health Coverage*

supply of these ensures.

spending to GDP growth.

cially redirecting it.

other federated entities (**Table 1**):

the health-care model; and the introduction of new management mechanisms that include the participation of society after a long period of restrictions on freedom. This was a major challenge especially for a country with more than 5000 municipalities and deep inequalities between them, both in the capacity to provide services and

The political conditions for implementing the reform were not very favorable. These include the national and international context marked by the reordering of the role of the state and the state-market relationship in favor of the second and of restriction to universalist policies; the conservative configuration of government coalitions that succeeded the period of democratic transition, in tune with the international environment, which prioritized the processes of adjustment and economic stabilization, accompanied by structural reforms, in the opposite direction to the expansion of government functions and rights enshrined in the constitution; the fragmentation of the health movement and the idealizer of the reform, from the process of democratization, when its heterogeneities and party cleavages were evidenced; the absence of organized support from the main beneficiaries of the SUS, located in the lower social strata; and the fragile and contradictory support of the organized segment of the workers, the majority covered by private health ensures and who did not have immediate interests in a universal system and usually included in their labor agenda the

Given the redistributive character of the health reform, broader coalitions would be necessary for its effectiveness, which proved to be very difficult given the political composition of the health arena constituted by different actors and interests configured throughout the health trajectory, as providers of private services, various modalities of health insurance operators, users of private health insurance, etc. To reach the ultimate goals of the reform, financing was an indispensable resource, involving not only the volume but also the way federal resources were transferred to states and municipalities, since decentralization was made dependent on federal resources. There is a great consensus among analysts and managers in Brazil that financing has been the greatest obstacle to the implementation of the constitutional right to health, but politically the process of its definition has been conflicting, in contexts of restrictive spending policies and lack of definition of sources of financing. After a period of great instability in funding and as a result of pressure from the defense coalition of the SUS, Constitutional Amendment No. 29 was approved in 2000. This amendment defined minimum resources for the financing of public health actions and services in the form of linking budgetary resources of the states and municipalities to health (12 and 15% of their revenues, respectively), and although it established fewer binding rules for the Union, it linked its

Contradictory, in 1998, while discussing the linking of resources to the SUS, the Law 9665 was approved, which regulated private health insurance and plans, and indicated the government's interest in leveraging the growth of the private market. This regulation formalized the duality of the Brazilian health system and politically weakened the proposal of a universal system, although the regulatory process was made independently of national health policy and without even denying or offi-

The application of CE 29 has in fact established a sharing between federated entities of health spending and allowed for greater stability in financing, in addition to continuous resource growth, particularly by increasing the expenditures of subnational entities, with a progressive relative decrease in the participation of the Union in the costing of the SUS, although it is still much higher than the expenses of

in socioeconomic conditions and in the health situation and needs [11].

**94**

*Public expenditure on health care by government sphere (%).*

However, there is a consensus that resources are insufficient to finance a universal system. In addition to spending relatively little on health (only 6.8% of total public spending and 3.8% of GDP), public health expenditure was US\$439.61 in 2014, corresponding to only 46.4% of total spending in health [14]. Pressures for the expansion of resources destined to SUS permeate the history of the sector. A positive response from the National Congress in this regard was the approval of Law 12,858/2013, which included health in the sharing of resources derived from oil royalties, in a context in which the country celebrated the discovery of oil reserves in the pre-salt layer.

Even within a framework of underfunding considering the characteristic of the universality and integrality of the right to health in Brazil, relevant efforts have been made since the 1990s to make these principles a reality. There was, in fact, the implementation of a universal system with a certain standardization of health policy in a country of continental dimensions. This was favored by federal coordination exercised by the federal government, particularly in the form of incentives and regulation of financial transfers, as well as in the form of federative pacts. The SUS is responsible for the vast majority of health services provided in the country and for the total coverage of approximately 75% of the population, since approximately one quarter of it is a beneficiary of private health insurance. In addition, it serves the total population for certain procedures—cases in which the situation of double coverage of citizens with private coverage is characterized since they do not fail to justify universal public service. These procedures include emergency and emergency care, the use of the Mobile Emergency Care Service (SAMU), blood transfusion, transplants, vaccination programs, some high-cost procedures, and, of course, all actions of a collective nature that affect the population as a whole, such as sanitary and epidemiological surveillance. For example, in 2018, the SUS financed more than 11 million hospitalizations and performed more than 3 billion outpatient care [15].

One of the SUS's guidelines is integral care, with priority for preventive activities. Since the 1990s it has been sought to reorganize the care model, seeking to revert the logic of emergency care, generally focused on hospital care, which had characterized health care until then, but with high cost and low effectiveness. To that end, policies and actions were defined, along with financial incentives from the Union to strengthen primary health care more strongly in the 2000s.

SUS is present throughout the Brazilian territory, including isolated indigenous villages and rural settlements, even with regional and local variations due to diverse financial capacity. The distributive and regulatory role of the federal government is fundamental to allow more homogeneity of assistance. The Brazilian public health system is conceived as a federative pact between three government entities and, based on their articulation and cooperation, aims to guarantee the universality and integrality of health care throughout Brazil. Although there is a sharing of functions, the central government concentrates the authority on decision-making process and in the policy regulation, while subnational governments, particularly municipalities, as federated entities with political autonomy, are responsible for

#### **Figure 1.**

*Institutional and decisional arrangement of SUS. Source: Adapted from Noronha et al., 2008 [16].*

policy-making; the states are expected to play the role of coordinating federative pacts between municipalities in their respective jurisdictions and may also be responsible for the provision of more complex services. Institutionalized (tripartite, bipartite regional) committees with normative power aggregate the managers of the different levels of government and are spaces for negotiation and agreement on administrative and financial issues, functioning as federative arenas that articulate the federated entities with shared functions in a national health system organized according to national and binding rules.

It is also worth noting that the participation of society is legally provided by deliberative councils and health conferences, both at the three levels of government. These collegiate instances complete the institutional arrangement of SUS, as illustrated in **Figure 1**.

#### **4. The political turn and the environment of uncertainties: 2015–2019**

The materialization of the right to health through the implementation of a universal health system is the result of the post-constitution democratic governments that were challenged to implant SUS, even resistant or facing resistance to the change of status quo. In the 1990s political-institutional advances led toward institutional reorganization, such as the unification of the policy; the construction of the institutional and decision-making framework of the SUS, respecting the federative organization and the social participation guideline; the decentralization and strengthening of municipal health systems; the expansion of actions and services in the national territory; the initial efforts to reorganize the care model with emphasis on primary care; and, at the end of the decade, the definition of new and stable sources of financing. Paradoxically, also at the end of the decade, the regulation of private health plans was formalized, formalizing the dual nature of health care and the cleavage between population covered by private insurance and that covered by the public insurance.

In the twenty-first century, from 2003 to May 2016, Brazil had national governments headed by presidents of the Workers' Party (PT), whose main brand had focused on social policies and the search for reduction of inequalities through development with inclusion. A set of social and economic policies of the period

**97**

the country.

These include:

*The Brazilian Unified Health System: Thirty Years of Advances and Resistance*

had a potential impact on conditions and health status, acting on the first dimension of the right to health defined in FC 1988. The fight against hunger and misery deserved special attention, including income transfer programs and agrarian development policy, besides fight against racism and racial inequalities, constitution of social assistance policy, growth of the social security coverage rate through measures aimed at reducing informal work, implementation of an urban develop-

However, starting in 2015, one of the country's biggest political and institutional crises begins, with strong repercussions on the future of Brazilian social policies, including health policy. President Dilma Rousseff from the start of her second term in 2015 had the subject of a strong campaign for her removal and the target of an oppositional attack that manifested by the total boycott of her government and the government's capacity. Started by the party that lost the elections (PSDB), the impeachment movement of the newly elected president gained supporters among sectors and more conservative parties, business sectors, and part of the middle class. The signs of an economic crisis and the unraveling of investigations into corruption in the state-owned Petrobras company that reached the political support base of the government provided ammunition for the opposition, strongly supported by the mainstream media, that managed to mobilize significant sectors of the population from the motto of the fight against corruption, leading to the gradual loss of government support and popularity. In the midst of this movement, and articulated to it, the public sphere began to express conservative Government Proposals and restrictions on state action, in clear opposition to the policies developed in the last two decades in

The outcome of this process was the removal of the president, provisionally in May and definitely on August 31, 2016, after a process that observed the constitution in rites and procedures but was quite debatable in its substance to not be able to unambiguously characterize a crime of responsibility of the president, which would provide the constitutional justification for its deposition. Vice-president Michel Temer assumes the government—active articulator of the process of impeachment with a large majority in the congress and with proposals for deep and structural reforms, both in the economic area and in social and labor policies and in the field of foreign policy. An accelerated process of constitutional change and the deconstruction of the status quo begin under the cloak of severe fiscal adjustment and "modernization," with a cut in public expenditures, privatizations, and threats to social policies capable of rendering ineffective rights enshrined in the constitution. Regarding health policy, specifically with regard to its financing, some decisions, on the one hand, indicate restrictions on the financing of the SUS and, on the other hand, signify changes in the principles on which the health system is based.

a. Establishment of the *new fiscal regime*, which aims to establish, for 20 years, ceilings for primary expenses (excluding interest payments) within the Union, which are limited to the variation of the inflation index as measured by the Extended National Consumer Price Index (IPCA) and based on 2016 expenses; this ceiling mitigates the binding nature of constitutionally defined health

b.Government Proposals to strengthen and expand private health insurance, justified by the need to "rethink" constitutional rights such as universal access to health, on the grounds that the country is supposed to be unable to support them anymore. These proposals were translated into the creation of an "affordable health insurance" with a lower cost and a list of services lower than the

expenditures and affects all social policies.

*DOI: http://dx.doi.org/10.5772/intechopen.86834*

ment policy, and recovery of minimum wage values.

#### *The Brazilian Unified Health System: Thirty Years of Advances and Resistance DOI: http://dx.doi.org/10.5772/intechopen.86834*

had a potential impact on conditions and health status, acting on the first dimension of the right to health defined in FC 1988. The fight against hunger and misery deserved special attention, including income transfer programs and agrarian development policy, besides fight against racism and racial inequalities, constitution of social assistance policy, growth of the social security coverage rate through measures aimed at reducing informal work, implementation of an urban development policy, and recovery of minimum wage values.

However, starting in 2015, one of the country's biggest political and institutional crises begins, with strong repercussions on the future of Brazilian social policies, including health policy. President Dilma Rousseff from the start of her second term in 2015 had the subject of a strong campaign for her removal and the target of an oppositional attack that manifested by the total boycott of her government and the government's capacity. Started by the party that lost the elections (PSDB), the impeachment movement of the newly elected president gained supporters among sectors and more conservative parties, business sectors, and part of the middle class. The signs of an economic crisis and the unraveling of investigations into corruption in the state-owned Petrobras company that reached the political support base of the government provided ammunition for the opposition, strongly supported by the mainstream media, that managed to mobilize significant sectors of the population from the motto of the fight against corruption, leading to the gradual loss of government support and popularity. In the midst of this movement, and articulated to it, the public sphere began to express conservative Government Proposals and restrictions on state action, in clear opposition to the policies developed in the last two decades in the country.

The outcome of this process was the removal of the president, provisionally in May and definitely on August 31, 2016, after a process that observed the constitution in rites and procedures but was quite debatable in its substance to not be able to unambiguously characterize a crime of responsibility of the president, which would provide the constitutional justification for its deposition. Vice-president Michel Temer assumes the government—active articulator of the process of impeachment with a large majority in the congress and with proposals for deep and structural reforms, both in the economic area and in social and labor policies and in the field of foreign policy. An accelerated process of constitutional change and the deconstruction of the status quo begin under the cloak of severe fiscal adjustment and "modernization," with a cut in public expenditures, privatizations, and threats to social policies capable of rendering ineffective rights enshrined in the constitution.

Regarding health policy, specifically with regard to its financing, some decisions, on the one hand, indicate restrictions on the financing of the SUS and, on the other hand, signify changes in the principles on which the health system is based. These include:


*Universal Health Coverage*

policy-making; the states are expected to play the role of coordinating federative pacts between municipalities in their respective jurisdictions and may also be responsible for the provision of more complex services. Institutionalized (tripartite, bipartite regional) committees with normative power aggregate the managers of the different levels of government and are spaces for negotiation and agreement on administrative and financial issues, functioning as federative arenas that articulate the federated entities with shared functions in a national health system organized

*Institutional and decisional arrangement of SUS. Source: Adapted from Noronha et al., 2008 [16].*

It is also worth noting that the participation of society is legally provided by deliberative councils and health conferences, both at the three levels of government. These collegiate instances complete the institutional arrangement of SUS, as

**4. The political turn and the environment of uncertainties: 2015–2019**

The materialization of the right to health through the implementation of a universal health system is the result of the post-constitution democratic governments that were challenged to implant SUS, even resistant or facing resistance to the change of status quo. In the 1990s political-institutional advances led toward institutional reorganization, such as the unification of the policy; the construction of the institutional and decision-making framework of the SUS, respecting the federative organization and the social participation guideline; the decentralization and strengthening of municipal health systems; the expansion of actions and services in the national territory; the initial efforts to reorganize the care model with emphasis on primary care; and, at the end of the decade, the definition of new and stable sources of financing. Paradoxically, also at the end of the decade, the regulation of private health plans was formalized, formalizing the dual nature of health care and the cleavage between population covered by private insurance and that covered by the public insurance. In the twenty-first century, from 2003 to May 2016, Brazil had national governments headed by presidents of the Workers' Party (PT), whose main brand had focused on social policies and the search for reduction of inequalities through development with inclusion. A set of social and economic policies of the period

according to national and binding rules.

illustrated in **Figure 1**.

**Figure 1.**

**96**

mandatory minimum established by the National Agency of Supplementary Health (ANS), as well as proposals for changes in the regulation of the supplementary health sector, very favorable to the operators, to the detriment of the users.

c.Changes in the format of intergovernmental relations, with a reduction in the role of federal coordination by the federal government.

The recent agenda thus points to the underfunding of the SUS, deregulation of the system with reduction of federal coordination, and expansion of the private sector with less regulation. It foresees a new health reform "inside" and without fanfare, which without denying the SUS will make it systemic if it is implemented [17].

It is beyond the scope of this article to analyze the political-institutional crisis in Brazil that began in 2015, but I would like to emphasize here one of its effects which was the intensification of political cleavages, which had many consequences, particularly in the electoral process. Firstly, it prevented the country's main popular leader from running for the 2018 presidential elections, arrested on charges of corruption that were not proven materially and from a highly questionable legal process both nationally and internationally. Secondly, the crisis allowed the victory of an extreme right-wing politician who proclaimed in discourse the deconstruction for the construction of a new country and that has as economic minister a radical liberal, supported by business sectors that give support to the new government.

The current period may represent the beginning of a new cycle whose contours are delineated, but whose results are still unpredictable. Democracy also seems threatened in one of its foundations which is a guarantee of social rights which has the utopia of greater substantive equality, beyond legal-formal equality, as one of its foundations. It is worth remembering that the concept of social policy has become inseparable from the notion of citizenship, which implies the establishment of a set of rights and duties between the citizen and the state and, fundamentally, the recognition of equality among citizens. It is, therefore, an egalitarian notion that relates to the construction of democracy—a political system based on the assumption of a basic equality among citizens. But even in democratic contexts, social policies tend to be subject to normative controversies involving conceptions of the role of the state and of justice. In the last decades, a great debate about these rights has been experienced in a context of persistent and widespread economic crisis. On one side, there are some interpretations, which emphasize the cost of social policies and consider the maintenance of these rights unsustainable, on the other hand, in different visions, social policies are seen as investment and producers of a more just and sustainable development, especially in countries which have not yet reached adequate levels of development.

In Brazil today, the first vision prevails in the government sphere and the attack against social policies, and the rights they represent are not an isolated event, but are linked to a set of governmental decisions and actions that form a coherent and articulated whole that points to changes in the way the Brazilian state operates, which directly affects social policies. Instead of isolated actions, we have actions that are concatenated with a view to redirect the interventionist or more proactive state standard (both with measures aimed at the development of the economy and at mitigating the perverse effects of the market economy) toward a market society with few state moorings. This would translate not only into more visible processes such as privatizations, sale of public assets, outsourcing, and incentives to market development in areas traditionally attributed to the state, such as health, but in deregulation processes (in various fields). Among these, the reform of labor legislation that has already been implemented is a great example of considerably

**99**

**Author details**

Telma Maria Gonçalves Menicucci

provided the original work is properly cited.

*The Brazilian Unified Health System: Thirty Years of Advances and Resistance*

from a systemic unfeasibility that could lead to its degradation.

Federal University of Minas Gerais, Belo Horizonte, Brazil

\*Address all correspondence to: tgmenicucci@gmail.com

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

reducing state regulation of the relationship between the employer and employee in a situation of great disparity in bargaining power due to high unemployment rates, which in practice allows and accentuates the suspension of guarantees established in previous legislation. This reform tends to increase worker informality and instability, and this outcome, in turn, should have an impact on the very sustainability of social security (which is also the subject of a reform proposal), as more precarious employment ties will have negative effects on the collection of social and pension contributions by workers and companies and, therefore, in the financing part of the

The commemoration of the 30 years of the Brazilian constitution, dubbed as "citizen constitution" for the rights it enshrines, among them the right to health, coexists with an ongoing process of deconstruction or of a larger institutional change in which the association between economic and social development, which was the hallmark of previous governments, loses strength in the current political conjuncture, as well as the proactive role of the state in this regard. Although the developments in this process are not given yet, the current period signals a new cycle of social policies in the opposite direction of the Federal Constitution of 1988. If the right to health implies a state guarantee of the adoption of public policies that avoid the risk of harm to health, considering all the health determinants, such as healthy environment, income, work, sanitation, food, and education, as well as the guarantee of health services that promote, protect, and recover individual and collective health, the Brazilian future does not seem promising. In all of these areas, there is an institutional deconstruction in Brazil, which includes cutting resources and changing legislation in the sense of social deprotection and market favoring in the context of an exacerbated and authoritarian liberalism. In the case of health, after three decades of building a universal and integral system, it is predicted that the system will be exhausted, even if it is not programmatically denied; it can suffer

*DOI: http://dx.doi.org/10.5772/intechopen.86834*

social policies in force.

#### *The Brazilian Unified Health System: Thirty Years of Advances and Resistance DOI: http://dx.doi.org/10.5772/intechopen.86834*

reducing state regulation of the relationship between the employer and employee in a situation of great disparity in bargaining power due to high unemployment rates, which in practice allows and accentuates the suspension of guarantees established in previous legislation. This reform tends to increase worker informality and instability, and this outcome, in turn, should have an impact on the very sustainability of social security (which is also the subject of a reform proposal), as more precarious employment ties will have negative effects on the collection of social and pension contributions by workers and companies and, therefore, in the financing part of the social policies in force.

The commemoration of the 30 years of the Brazilian constitution, dubbed as "citizen constitution" for the rights it enshrines, among them the right to health, coexists with an ongoing process of deconstruction or of a larger institutional change in which the association between economic and social development, which was the hallmark of previous governments, loses strength in the current political conjuncture, as well as the proactive role of the state in this regard. Although the developments in this process are not given yet, the current period signals a new cycle of social policies in the opposite direction of the Federal Constitution of 1988.

If the right to health implies a state guarantee of the adoption of public policies that avoid the risk of harm to health, considering all the health determinants, such as healthy environment, income, work, sanitation, food, and education, as well as the guarantee of health services that promote, protect, and recover individual and collective health, the Brazilian future does not seem promising. In all of these areas, there is an institutional deconstruction in Brazil, which includes cutting resources and changing legislation in the sense of social deprotection and market favoring in the context of an exacerbated and authoritarian liberalism. In the case of health, after three decades of building a universal and integral system, it is predicted that the system will be exhausted, even if it is not programmatically denied; it can suffer from a systemic unfeasibility that could lead to its degradation.

#### **Author details**

*Universal Health Coverage*

users.

mandatory minimum established by the National Agency of Supplementary Health (ANS), as well as proposals for changes in the regulation of the supplementary health sector, very favorable to the operators, to the detriment of the

c.Changes in the format of intergovernmental relations, with a reduction in the

The recent agenda thus points to the underfunding of the SUS, deregulation of the system with reduction of federal coordination, and expansion of the private sector with less regulation. It foresees a new health reform "inside" and without fanfare, which without denying the SUS will make it systemic if it is implemented [17]. It is beyond the scope of this article to analyze the political-institutional crisis in Brazil that began in 2015, but I would like to emphasize here one of its effects which was the intensification of political cleavages, which had many consequences, particularly in the electoral process. Firstly, it prevented the country's main popular leader from running for the 2018 presidential elections, arrested on charges of corruption that were not proven materially and from a highly questionable legal process both nationally and internationally. Secondly, the crisis allowed the victory of an extreme right-wing politician who proclaimed in discourse the deconstruction for the construction of a new country and that has as economic minister a radical liberal, supported by business sectors that give support to the new government. The current period may represent the beginning of a new cycle whose contours are delineated, but whose results are still unpredictable. Democracy also seems threatened in one of its foundations which is a guarantee of social rights which has the utopia of greater substantive equality, beyond legal-formal equality, as one of its foundations. It is worth remembering that the concept of social policy has become inseparable from the notion of citizenship, which implies the establishment of a set of rights and duties between the citizen and the state and, fundamentally, the recognition of equality among citizens. It is, therefore, an egalitarian notion that relates to the construction of democracy—a political system based on the assumption of a basic equality among citizens. But even in democratic contexts, social policies tend to be subject to normative controversies involving conceptions of the role of the state and of justice. In the last decades, a great debate about these rights has been experienced in a context of persistent and widespread economic crisis. On one side, there are some interpretations, which emphasize the cost of social policies and consider the maintenance of these rights unsustainable, on the other hand, in different visions, social policies are seen as investment and producers of a more just and sustainable development, especially in countries which have not yet reached

In Brazil today, the first vision prevails in the government sphere and the attack against social policies, and the rights they represent are not an isolated event, but are linked to a set of governmental decisions and actions that form a coherent and articulated whole that points to changes in the way the Brazilian state operates, which directly affects social policies. Instead of isolated actions, we have actions that are concatenated with a view to redirect the interventionist or more proactive state standard (both with measures aimed at the development of the economy and at mitigating the perverse effects of the market economy) toward a market society with few state moorings. This would translate not only into more visible processes such as privatizations, sale of public assets, outsourcing, and incentives to market development in areas traditionally attributed to the state, such as health, but in deregulation processes (in various fields). Among these, the reform of labor legislation that has already been implemented is a great example of considerably

role of federal coordination by the federal government.

**98**

adequate levels of development.

Telma Maria Gonçalves Menicucci Federal University of Minas Gerais, Belo Horizonte, Brazil

\*Address all correspondence to: tgmenicucci@gmail.com

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

#### **References**

[1] dos Santos WG. Cidadania e Justiça (Citizenship and Justice). Rio de Janeiro: Campos; 1979

[2] Braga JC, Paula SG. Saúde e Previdência: Estudos de Política Social (Health and Welfare: Social Policy studiEs). São Paulo: Cebes Hucitec; 1981

[3] Brazilian Institute of Geography and Statistics (IBGE). Health Statistics— Pesquisa de Assistência Médica-Sanitária (Survey of Medical-Health Care); 1999

[4] Menicucci Telma MG. Público e Privado na Política de Assistência à Saúde no Brasil: Atores, Processos e Trajetória (Public and Private Health Care Policy in Brazil: Actors, Processes and Trajectory). Rio de Janeiro: Fiocruz; 2007

[5] Giffoni RM. Público e Privado na Política de Assistência à Saúde no Brasil: Atores, Processos e Trajetória (Medical Assistance and Work Relationships in the Company: The Model of Agreement with Social Security) [Master's dissertation]. São Paulo: University of São Paulo; 1991

[6] Faveret PF, Oliveira PJ. A universalização excludente: Reflexões sobre as tendências do Sistema de Saúde (the exclusionary universalization: Reflections on the trends of the health system). DADOS-Revista de Ciências Sociais. 1990;**33**(2):257-283

[7] Bahia L. Planos e Seguros Saúde: Padrões e Mudanças das Relações Entre o Público e o Privado no Brasil (Plans and Health Insurance: Patterns and Changes in Public-Private Relations in Brazil) [Doctoral thesis]. Rio de Janeiro: National School of Public Health, Oswaldo Cruz Foundation; 1999

[8] Rodrigues Neto EE. A via do parlamento (The way of the parliament). In: Fleury S, editor. Saúde e Democracia: A Luta Do CEBES (Health and

Democracy: The Struggle of CEBES). São Paulo: Lemos Editorial; 1997

[9] Gerschman S. A Democracia Inconclusa: Um Estudo da Reforma Sanitária Brasileira (The Unfinished Democracy: A Study of Brazilian Sanitary Reform). Rio de Janeiro: Fiocruz Publishing House; 1995

[10] World Health Organization. Resolution Adopted by the General Assembly. 2012. Available from: https:// www.un.org/en/ga/search/view\_doc. asp?symbol=A/RES/67/81

[11] Menicucci T. A Relação Entre o Público-Privado e o Contexto Federativo Do SUS: Uma análise Institucional (The Relation Between The Public-Private and The Federative Context of SUS: An Institutional Analysis). Series Social Policies. Vol. 196. Santiago: CEPAL; 2014

[12] SIOPS/MS. Health Information System/Ministry of Health

[13] Piola SF, Benevidesm RPS, Vieira FS. Consolidação Do Gasto Com Ações e Serviços Públicos de Saúde: Trajetória e Percalços no Período de 2003 a 2017 (Consolidation of Spending on Public Health Actions and Services: Trajectory and Mishaps in the Period from 2003 to 2017). Text for Discussion 2439. Rio de Janeiro: IPEA; 2018

[14] Figueiredo JO, Prado NMBL, Medina MG, Paim JS. Gastos Público e Privado Com Saúde no Brasil e Países Selecionados (Public and Private Health Expenditures in Brazil and Selected Countries). Health Debate; Rio de Janeiro. Vol. 42, Special Issue 22018. pp. 37-47

[15] DATASUS. SUS Department of Informatics. Ministry of Health

[16] Noronha JC, Lima LD, Machado CV. O sistema único de saúde—SUS (The unified health system—SUS). In:

**101**

*The Brazilian Unified Health System: Thirty Years of Advances and Resistance*

*DOI: http://dx.doi.org/10.5772/intechopen.86834*

[17] Telma M. Política de saúde do Brasil: Continuidades e inovações (Health policy in Brazil: Continuities and innovations). In: Arretche M, Marques E, Faria CA, editors. As Políticas Da Política: Desigualdades e Inclusão Nos Governos Do PSDB e Do PT (Policy' Politics: Inequalities and Inclusion in the Governments of the PSDB and PT). No

Giovanella L, Escorel S, Lobato LVC, Noronha JC, Carvalho AI, editors. Políticas e Sistema de Saúde no Brasil. (Policies and Health System in Brazil). Rio de Janeiro: Fiocruz Publishing

House; 2008

press; 2019

*The Brazilian Unified Health System: Thirty Years of Advances and Resistance DOI: http://dx.doi.org/10.5772/intechopen.86834*

Giovanella L, Escorel S, Lobato LVC, Noronha JC, Carvalho AI, editors. Políticas e Sistema de Saúde no Brasil. (Policies and Health System in Brazil). Rio de Janeiro: Fiocruz Publishing House; 2008

[17] Telma M. Política de saúde do Brasil: Continuidades e inovações (Health policy in Brazil: Continuities and innovations). In: Arretche M, Marques E, Faria CA, editors. As Políticas Da Política: Desigualdades e Inclusão Nos Governos Do PSDB e Do PT (Policy' Politics: Inequalities and Inclusion in the Governments of the PSDB and PT). No press; 2019

**100**

*Universal Health Coverage*

Campos; 1979

**References**

[1] dos Santos WG. Cidadania e Justiça (Citizenship and Justice). Rio de Janeiro: Democracy: The Struggle of CEBES). São Paulo: Lemos Editorial; 1997

[9] Gerschman S. A Democracia Inconclusa: Um Estudo da Reforma Sanitária Brasileira (The Unfinished Democracy: A Study of Brazilian Sanitary Reform). Rio de Janeiro: Fiocruz Publishing House; 1995

[10] World Health Organization. Resolution Adopted by the General Assembly. 2012. Available from: https:// www.un.org/en/ga/search/view\_doc.

[11] Menicucci T. A Relação Entre o Público-Privado e o Contexto Federativo Do SUS: Uma análise Institucional (The Relation Between The Public-Private and The Federative Context of SUS: An Institutional Analysis). Series Social Policies. Vol. 196. Santiago: CEPAL; 2014

[12] SIOPS/MS. Health Information

[13] Piola SF, Benevidesm RPS, Vieira FS. Consolidação Do Gasto Com Ações e Serviços Públicos de Saúde: Trajetória e Percalços no Período de 2003 a 2017 (Consolidation of Spending on Public Health Actions and Services: Trajectory and Mishaps in the Period from 2003 to 2017). Text for Discussion 2439. Rio de

[14] Figueiredo JO, Prado NMBL, Medina MG, Paim JS. Gastos Público e Privado Com Saúde no Brasil e Países Selecionados (Public and Private Health Expenditures in Brazil and Selected Countries). Health Debate; Rio de Janeiro. Vol. 42, Special

[15] DATASUS. SUS Department of Informatics. Ministry of Health

[16] Noronha JC, Lima LD, Machado CV. O sistema único de saúde—SUS (The unified health system—SUS). In:

System/Ministry of Health

Janeiro: IPEA; 2018

Issue 22018. pp. 37-47

asp?symbol=A/RES/67/81

Previdência: Estudos de Política Social (Health and Welfare: Social Policy studiEs). São Paulo: Cebes Hucitec; 1981

[3] Brazilian Institute of Geography and Statistics (IBGE). Health Statistics— Pesquisa de Assistência Médica-Sanitária (Survey of Medical-Health Care); 1999

[4] Menicucci Telma MG. Público e Privado na Política de Assistência à Saúde no Brasil: Atores, Processos e Trajetória (Public and Private Health Care Policy in Brazil: Actors, Processes and Trajectory).

[5] Giffoni RM. Público e Privado na Política de Assistência à Saúde no Brasil: Atores, Processos e Trajetória (Medical Assistance and Work Relationships in the Company: The Model of Agreement

with Social Security) [Master's dissertation]. São Paulo: University of

[6] Faveret PF, Oliveira PJ. A

Sociais. 1990;**33**(2):257-283

universalização excludente: Reflexões sobre as tendências do Sistema de Saúde (the exclusionary universalization: Reflections on the trends of the health system). DADOS-Revista de Ciências

[7] Bahia L. Planos e Seguros Saúde: Padrões e Mudanças das Relações Entre o Público e o Privado no Brasil (Plans and Health Insurance: Patterns and Changes in Public-Private Relations in Brazil) [Doctoral thesis]. Rio de Janeiro: National School of Public Health, Oswaldo Cruz Foundation; 1999

[8] Rodrigues Neto EE. A via do

A Luta Do CEBES (Health and

parlamento (The way of the parliament). In: Fleury S, editor. Saúde e Democracia:

São Paulo; 1991

Rio de Janeiro: Fiocruz; 2007

[2] Braga JC, Paula SG. Saúde e

**103**

**Chapter 8**

of Italy

*Stefano Neri*

debate on the future of the healthcare system.

**Abstract**

economic crisis

**1. Introduction**

Economic Crisis, Decentralisation

and Health Inequalities: The Case

The chapter describes the recent evolution of the Italian National Health Service (NHS), highlighting the potential and effective consequences of the economic and financial crisis on social and territorial inequalities, especially in terms of service access and quality. First, it analyses the cost-containment and austerity policies in the NHS, which brought to a relevant underfunding of the public healthcare system, comparing public expenditure trends in Italy with those of other Western European countries. Then, it stresses the increasing role played by private expenditure, emphasizing the risks in terms of health inequalities connected to the high level of out-of-pocket payments and to the spread of the occupational funds. Finally, a reconstruction and analysis of the current changes in the NHS governance is carried out, explaining in details how the reassertion of the role of the Central State in health policy entails different consequences for different areas of Italy, widening the territorial inequalities and increasing the North-South divide. So far, these changes have taken place without any structural reform, in an imperceptible but progressive way, which does not help to develop an appropriate and necessary

**Keywords:** healthcare, decentralisation, national health service, health inequalities,

Since the Italian unification (1861), the Italian healthcare system has fully changed its institutional model at least three times. From being substantially 'residual' during the liberal era (1861–1921) and also the fascist decades (1922– 1943), with a gradual spread of corporate health funds and some compulsory insurance schemes targeted on specific illnesses [1], it shifted to a social health insurance system at the end of the fascism, which was developed after the end of the Second World War, during the first 30 years of the Republic (1945–1977); finally, an universalist National Health Service (NHS) was instituted in 1978 (Law no. 833). Structural changes were then adopted in 1992–1993 (Legislative Decrees no. 502/1992 and no. 517/1993), introducing managerialisation and managed competition, which was softened in 1999 (Legislative Decree no. 229/1999), while Constitutional Law no. 3/2001 recognised, at constitutional level, and strengthened

the regionalisation of the healthcare system carried out during the 1990s [2].

#### **Chapter 8**

## Economic Crisis, Decentralisation and Health Inequalities: The Case of Italy

*Stefano Neri*

#### **Abstract**

The chapter describes the recent evolution of the Italian National Health Service (NHS), highlighting the potential and effective consequences of the economic and financial crisis on social and territorial inequalities, especially in terms of service access and quality. First, it analyses the cost-containment and austerity policies in the NHS, which brought to a relevant underfunding of the public healthcare system, comparing public expenditure trends in Italy with those of other Western European countries. Then, it stresses the increasing role played by private expenditure, emphasizing the risks in terms of health inequalities connected to the high level of out-of-pocket payments and to the spread of the occupational funds. Finally, a reconstruction and analysis of the current changes in the NHS governance is carried out, explaining in details how the reassertion of the role of the Central State in health policy entails different consequences for different areas of Italy, widening the territorial inequalities and increasing the North-South divide. So far, these changes have taken place without any structural reform, in an imperceptible but progressive way, which does not help to develop an appropriate and necessary debate on the future of the healthcare system.

**Keywords:** healthcare, decentralisation, national health service, health inequalities, economic crisis

#### **1. Introduction**

Since the Italian unification (1861), the Italian healthcare system has fully changed its institutional model at least three times. From being substantially 'residual' during the liberal era (1861–1921) and also the fascist decades (1922– 1943), with a gradual spread of corporate health funds and some compulsory insurance schemes targeted on specific illnesses [1], it shifted to a social health insurance system at the end of the fascism, which was developed after the end of the Second World War, during the first 30 years of the Republic (1945–1977); finally, an universalist National Health Service (NHS) was instituted in 1978 (Law no. 833). Structural changes were then adopted in 1992–1993 (Legislative Decrees no. 502/1992 and no. 517/1993), introducing managerialisation and managed competition, which was softened in 1999 (Legislative Decree no. 229/1999), while Constitutional Law no. 3/2001 recognised, at constitutional level, and strengthened the regionalisation of the healthcare system carried out during the 1990s [2].

As a result, the NHS is structured on three levels: a national level, constituted mainly by the Ministry of Health; an intermediate level represented by the Regions and their Regional Ministers and health departments and a local operational level, directly accountable to the Regional one, made up of about 70–75 *Aziende sanitarie ospedaliere* (hospital trusts, henceforth HTs) and about 135–140 *Aziende sanitarie locali* (local health authorities, henceforth LHAs).

Since 2001, no major reforms have been introduced into the NHS. However, important changes have almost imperceptibly taken place, connected the economic and financial crisis, which are weakening the universalist nature of the NHS.

This chapter will analyse the evolution of the NHS in Italy during the last decade, hence in the years of the crisis, focusing on some trajectories of change underway, mainly in the health expenditure and in the NHS institutional framework governance. These trends might have important consequences in terms of service access and quality, increasing the traditional social and territorial inequalities and hence weakening the universalistic nature of the NHS.

### **2. What universalism? NHS performance between North and South**

According to international and national literature, the Italian NHS system performs relatively well in comparative terms, among both European and OECD countries, although it is questionable whether and to what extent some of the results reported in the adopted indicators are attributable to the healthcare system in itself. The OECD report *Health at a Glance* [3], which represents a systematic evaluation of the healthcare systems in 35 OECD countries, based on 76 indicators gathered in 9 categories or areas (health status, risk factors, access to care, quality of care and health outcomes, health expenditure, staff, care provision, pharmaceuticals, ageing and long-term care), the OECD *Health profile* on Italy [4] and the OECD/EU report *Health at a Glance: Europe 2018* all agree attributing, by and large, good results in terms of prevention, access and quality of care, mortality and survival rates as well as in terms of health expenditure and efficiency, with improvements in many areas compared with the beginning of the 2000s. However, as emerged not only by OECD reports but also by other literature, social inequalities are significant in many indicators related to dimensions such as health status, risk factors, access and quality of care [3–9].

In particular:


**105**

*Economic Crisis, Decentralisation and Health Inequalities: The Case of Italy*

• Avoidable mortality (preventable and amenable) is one of the lowest in

Europe, and also survival rates for different types of cancer and major cardiocirculatory illnesses are within the average or among the best found among

• In terms of access, the Italian NHS provides coverage to all citizens and foreign residents with a comprehensive care based on health needs, but social and

• In 2017, health expenditure was below the EU average, both in terms of per capita expenditure (2,551 Euro, −8.1% compared with the average EU level) and of share of the GDP (8.9, −0.6% compared with EU average). Although the NHS ensures a wide package of free services, out-of-pocket expenditure (23% of total health expenditure in 2015) is much higher than the EU average

• Long-term care is still lacking, with several indicators below the level of

However, as it is well known by NHS scholars, national figures reported in international statistics and comparisons hide the very relevant differences existing among different areas of countries, traditionally summarised in the North-South divide. In this respect, 1992–1993 reforms had introduced the 'Livelli Essenziali di Assistenza' (essential levels of healthcare), or LEAs, which include all the kinds of healthcare services to be provided by all the regions throughout the country. Every year Central State attributes to regions the amount of funds needed to the provision of this very wide service package, after a State-Regions negotiation based on an allocation defined according to per capita criteria, adjusted for the distribution of

Western European comparable countries, although there are signs of improve-

The LEAs, which were first released in 2001, are matched with a monitoring and control system based on a set of indicators which allow checking whether and to what extent regions are respecting and ensuring the LEAs in the healthcare service provision to their resident population. The indicators are grouped in three areas of healthcare (prevention; outpatient, community and home care; hospital care). For each area, a synthetic index is obtained from the relevant indicators, with scores which may vary between 0.00 and 100.0 points. The monitoring system is associ-

Last assessment carried out by the Ministry of Health in 2017 [10] showed the persistence of very relevant disparities among Regions, with Northern Regions nearly always having the best scores in most of the indicators of the three areas of healthcare. Moreover, differences in the scores are striking, going, in prevention, from 80.92/100.00 points by Lombardy to 48.48 by Sicily; in outpatient care, from 86.39/100.00 by Liguria to 29.05 by Campania and in hospital care, from 89.13/100.00 points by Tuscany to 25.41/100.00 points obtained by Campania. Although many indicators are focused on expenditure efficiency, they highlight also the very important territorial differences existing in terms of service access and

These differences are historically rooted. However, despite significant efforts especially addressed to reduce territorial differences in expenditure for health services [11], these were not translated into a correspondent reduction of the differences existing in terms of service quality and efficiency between different areas of the country. Quite the opposite, according to some studies, the North-South

*DOI: http://dx.doi.org/10.5772/intechopen.89006*

Western European comparable countries.

the population by age and epidemiological factors.

ated to incentives and sanctions in terms of attributed funds.

quality, in favour of Northern and Centre-Northern Regions.

territorial inequalities are relevant.

(15% in 2015).

ments in the last years.

*Economic Crisis, Decentralisation and Health Inequalities: The Case of Italy DOI: http://dx.doi.org/10.5772/intechopen.89006*

*Universal Health Coverage*

*locali* (local health authorities, henceforth LHAs).

ties and hence weakening the universalistic nature of the NHS.

As a result, the NHS is structured on three levels: a national level, constituted mainly by the Ministry of Health; an intermediate level represented by the Regions and their Regional Ministers and health departments and a local operational level, directly accountable to the Regional one, made up of about 70–75 *Aziende sanitarie ospedaliere* (hospital trusts, henceforth HTs) and about 135–140 *Aziende sanitarie* 

Since 2001, no major reforms have been introduced into the NHS. However, important changes have almost imperceptibly taken place, connected the economic and financial crisis, which are weakening the universalist nature of the NHS. This chapter will analyse the evolution of the NHS in Italy during the last decade, hence in the years of the crisis, focusing on some trajectories of change underway, mainly in the health expenditure and in the NHS institutional framework governance. These trends might have important consequences in terms of service access and quality, increasing the traditional social and territorial inequali-

**2. What universalism? NHS performance between North and South**

According to international and national literature, the Italian NHS system performs relatively well in comparative terms, among both European and OECD countries, although it is questionable whether and to what extent some of the results reported in the adopted indicators are attributable to the healthcare system in itself. The OECD report *Health at a Glance* [3], which represents a systematic evaluation of the healthcare systems in 35 OECD countries, based on 76 indicators gathered in 9 categories or areas (health status, risk factors, access to care, quality of care and health outcomes, health expenditure, staff, care provision, pharmaceuticals, ageing and long-term care), the OECD *Health profile* on Italy [4] and the OECD/EU report *Health at a Glance: Europe 2018* all agree attributing, by and large, good results in terms of prevention, access and quality of care, mortality and survival rates as well as in terms of health expenditure and efficiency, with improvements in many areas compared with the beginning of the 2000s. However, as emerged not only by OECD reports but also by other literature, social inequalities are significant in many indicators related to dimensions such as health status, risk factors, access and

• From 2000 to 2015, life expectancy at birth has increased from 79.9 to 82.7 years (the second best figure in the EU after Spain), thanks mostly to the decrease of the mortality for cardiovascular diseases. However, there are

• As far as risk factors are concerned, from 2000 to 2014, the rate of smokers has decreased from 25 to 20% slightly below the EU average. Also obesity rates decreased, but they remain considerably high, especially among children, with 18% of children aged 7–8 years in condition of obesity in 2017 (the second

• Coverage rates for several types of immunisation are at the level of the

comparable European countries, although they have slightly decreased after 2012–2013 (but it is expected to have increased again in most recent years in the case of children vaccinations). Conversely, rates of cancer screening have

**104**

quality of care [3–9]. In particular:

increased [6].

relevant gender and social inequalities.

highest level in Europe, 6 points over the EU average).


However, as it is well known by NHS scholars, national figures reported in international statistics and comparisons hide the very relevant differences existing among different areas of countries, traditionally summarised in the North-South divide. In this respect, 1992–1993 reforms had introduced the 'Livelli Essenziali di Assistenza' (essential levels of healthcare), or LEAs, which include all the kinds of healthcare services to be provided by all the regions throughout the country. Every year Central State attributes to regions the amount of funds needed to the provision of this very wide service package, after a State-Regions negotiation based on an allocation defined according to per capita criteria, adjusted for the distribution of the population by age and epidemiological factors.

The LEAs, which were first released in 2001, are matched with a monitoring and control system based on a set of indicators which allow checking whether and to what extent regions are respecting and ensuring the LEAs in the healthcare service provision to their resident population. The indicators are grouped in three areas of healthcare (prevention; outpatient, community and home care; hospital care). For each area, a synthetic index is obtained from the relevant indicators, with scores which may vary between 0.00 and 100.0 points. The monitoring system is associated to incentives and sanctions in terms of attributed funds.

Last assessment carried out by the Ministry of Health in 2017 [10] showed the persistence of very relevant disparities among Regions, with Northern Regions nearly always having the best scores in most of the indicators of the three areas of healthcare. Moreover, differences in the scores are striking, going, in prevention, from 80.92/100.00 points by Lombardy to 48.48 by Sicily; in outpatient care, from 86.39/100.00 by Liguria to 29.05 by Campania and in hospital care, from 89.13/100.00 points by Tuscany to 25.41/100.00 points obtained by Campania. Although many indicators are focused on expenditure efficiency, they highlight also the very important territorial differences existing in terms of service access and quality, in favour of Northern and Centre-Northern Regions.

These differences are historically rooted. However, despite significant efforts especially addressed to reduce territorial differences in expenditure for health services [11], these were not translated into a correspondent reduction of the differences existing in terms of service quality and efficiency between different areas of the country. Quite the opposite, according to some studies, the North-South

gap has been widened since the 1990s, that is, in the years of NHS regionalisation, instead of being reduced [12–14].

In this context, the economic crisis started in 2008–2009 triggered a set of policies which, on the one hand, risk to deepen the existing social inequalities in terms of service access; on the other hand, they caused a substantial change in the NHS governance which could seriously increase the territorial differences.

#### **3. The economic crisis and austerity policies in the NHS**

In Italy, the economic crisis started in 2008 was prolonged, with a fluctuating trend, characterised by two peaks (**Table 1**): the first was in 2008 and especially in 2009, when the Italian GDP declined by 1.1 and 5.5%, respectively, from the previous year. After an overall weak recovery in the following 2 years, in 2012, the crisis heightened and the GDP dropped by 2.8%, followed by a further decline of 1.7% in 2013. In 2014–2015, the GDP growth trend was very slack and became a little more sustained in 2016–2017 (respectively, 1.1 and 1.6%), but in 2018, it dropped down again below 1%, and also provisional data for 2019 indicate a further weakening of the economic recovery (Eurostat database). In all these years, the GDP growth rates were considerably lower than those of the 28 EU countries (**Table 1**). Similar differences emerge also considering only the countries within the Euro area.

The recession had a very strong impact on the relationship between the GDP and public debt. Since 1991–1992, this ratio had always been at more than 100%, one of the highest in Europe, except for 2007 (99.8%). However, since the start of the economic crisis, it has progressively increased surpassing the 130% of the GDP in 2014, with a tendency to level off over this level (**Table 2**).

Beyond the data, the crisis became particularly serious in 2011–2012, when the widespread perception, by the international markets and European institutions, that the Italian government was no longer able to bring the debt under control resulted in a sovereign debt crisis. This brought to the fall of the Berlusconi government, at the end of 2011, replaced by a 'technical' executive, headed by the economist Mario Monti. In the context of a protracted financial crisis and lack of confidence of the international environment, strict austerity measures were taken to control the budget deficit, reduce public sector expenses and increase public revenues [15]. While in policy areas such as pensions, these measures were accompanied by structural reforms; this was not the case in healthcare which was, however, object of severe cost-containment and retrenchment measures.

In the Italian highly regionalised NHS, control of health expenditure by the central government was pursued primarily through extremely limited increases, and, in some cases, reductions in the level of funding are attributed by the central government to the regions to finance the LEAs. The level of annual funding of LEAs is calculated in the budget laws, called 'stability laws', and it is negotiated between the State and the Regions within the State-Region Conference (see below) and


**107**

**Table 3.**

*\**

*Approximate.*

*Source: Ministero della Salute [16].*

*Financing of the central funding for LEAs.*

**Table 2.**

*Economic Crisis, Decentralisation and Health Inequalities: The Case of Italy*

the crisis with reductions in the originally agreed funds.

remains one of the central government priorities.

*Source: Eurostat: General government gross debt online database.*

*General government gross debt in Italy: percentage of GDP.*

ratified in official acts and documents such as the 'State-Region Agreements' or the 'Pacts for Health'. However, the Parliament and the central government can modify the concerted funding levels, as has always occurred in fact, after the beginning of

Absolute values and percentages of annual funding increases confirmed a stagnation in the central government financing from 2010 onwards, with very reduced surges but also drops compared with the previous years, in 2013 and in 2015 (**Table 3**). From 2010 to 2019, central funding increased by about 8,800,000,000 Euro, with a yearly average of about 0.9%, less than the average yearly inflation rate

Besides the containment of general central funding, austerity policies addressed

the control of specific sources of expenditure arising from the acquisition of production inputs. The main cost-containment programmes started in 2009 (Law Decree No. 39/2009) and 2010 (Law Decree No. 78/2010) and intensified in the following years, culminating in the so-called spending review on public administration, promoted by the Monti government in 2012 (Law Decree No. 95/2012, converted into Law No. 131/2012). The austerity measures then continued roughly until at least 2016, albeit with less intensity, and the cost-containment in healthcare

Main policies included spending caps and reduction in the pharmaceutical expenditure; decrease in hospitalisation rates and in the number of hospital beds per

**Financing (in Euro)\* Change compared with** 

 97,600,000,000 (4,400,000,000) (4.7) 101,600,000,000 4,000,000,000 4.1 104,200,000,000 2,600,000,000 2.6 105,600,000,000 1,400,000,000 1.3 106,900,000,000 1,300,000,000 1.2 108,000,000,000 1,100,000,000 1.0 107,000,000,000 −1,000,000,000 0.9 109,900,000,000 2,700,000,000 2.7 109,700,000,000 −200,000,000 −0.2 111,000,000,000 1,300,000,000 1.2 112,600,000,000 1,600,000,000 1.4 113,400,000,000 800,000,000 0.7 114,400,000,000 1,000,000,000 0.9

**2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018** 99.8 102.4 112.5 115.4 116.5 123.4 129 131.8 131.6 131.4 131.2 131.4

**previous year (in Euro)\***

**Change compared with previous year (%)**

*DOI: http://dx.doi.org/10.5772/intechopen.89006*

(about 1.1%; see [16, 17]).

**Table 1.** *GDP rates: percentage change on previous year.*

#### *Economic Crisis, Decentralisation and Health Inequalities: The Case of Italy DOI: http://dx.doi.org/10.5772/intechopen.89006*

ratified in official acts and documents such as the 'State-Region Agreements' or the 'Pacts for Health'. However, the Parliament and the central government can modify the concerted funding levels, as has always occurred in fact, after the beginning of the crisis with reductions in the originally agreed funds.

Absolute values and percentages of annual funding increases confirmed a stagnation in the central government financing from 2010 onwards, with very reduced surges but also drops compared with the previous years, in 2013 and in 2015 (**Table 3**). From 2010 to 2019, central funding increased by about 8,800,000,000 Euro, with a yearly average of about 0.9%, less than the average yearly inflation rate (about 1.1%; see [16, 17]).

Besides the containment of general central funding, austerity policies addressed the control of specific sources of expenditure arising from the acquisition of production inputs. The main cost-containment programmes started in 2009 (Law Decree No. 39/2009) and 2010 (Law Decree No. 78/2010) and intensified in the following years, culminating in the so-called spending review on public administration, promoted by the Monti government in 2012 (Law Decree No. 95/2012, converted into Law No. 131/2012). The austerity measures then continued roughly until at least 2016, albeit with less intensity, and the cost-containment in healthcare remains one of the central government priorities.

Main policies included spending caps and reduction in the pharmaceutical expenditure; decrease in hospitalisation rates and in the number of hospital beds per


*Source: Eurostat: General government gross debt online database.*

#### **Table 2.**

*Universal Health Coverage*

instead of being reduced [12–14].

gap has been widened since the 1990s, that is, in the years of NHS regionalisation,

governance which could seriously increase the territorial differences.

ences emerge also considering only the countries within the Euro area.

however, object of severe cost-containment and retrenchment measures.

In the Italian highly regionalised NHS, control of health expenditure by the central government was pursued primarily through extremely limited increases, and, in some cases, reductions in the level of funding are attributed by the central government to the regions to finance the LEAs. The level of annual funding of LEAs is calculated in the budget laws, called 'stability laws', and it is negotiated between the State and the Regions within the State-Region Conference (see below) and

**2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018**

3.1 0.5 -4.3 2.1 1.8 −0.4 0.3 1.8 2.3 2 2.4 2.0

Italy 1.5 −1.1 −5.5 1.7 0.6 −2.8 −1.7 0.1 0.9 1.1 1.6 0.9

2014, with a tendency to level off over this level (**Table 2**).

**3. The economic crisis and austerity policies in the NHS**

In this context, the economic crisis started in 2008–2009 triggered a set of policies which, on the one hand, risk to deepen the existing social inequalities in terms of service access; on the other hand, they caused a substantial change in the NHS

In Italy, the economic crisis started in 2008 was prolonged, with a fluctuating trend, characterised by two peaks (**Table 1**): the first was in 2008 and especially in 2009, when the Italian GDP declined by 1.1 and 5.5%, respectively, from the previous year. After an overall weak recovery in the following 2 years, in 2012, the crisis heightened and the GDP dropped by 2.8%, followed by a further decline of 1.7% in 2013. In 2014–2015, the GDP growth trend was very slack and became a little more sustained in 2016–2017 (respectively, 1.1 and 1.6%), but in 2018, it dropped down again below 1%, and also provisional data for 2019 indicate a further weakening of the economic recovery (Eurostat database). In all these years, the GDP growth rates were considerably lower than those of the 28 EU countries (**Table 1**). Similar differ-

The recession had a very strong impact on the relationship between the GDP and public debt. Since 1991–1992, this ratio had always been at more than 100%, one of the highest in Europe, except for 2007 (99.8%). However, since the start of the economic crisis, it has progressively increased surpassing the 130% of the GDP in

Beyond the data, the crisis became particularly serious in 2011–2012, when the widespread perception, by the international markets and European institutions, that the Italian government was no longer able to bring the debt under control resulted in a sovereign debt crisis. This brought to the fall of the Berlusconi government, at the end of 2011, replaced by a 'technical' executive, headed by the economist Mario Monti. In the context of a protracted financial crisis and lack of confidence of the international environment, strict austerity measures were taken to control the budget deficit, reduce public sector expenses and increase public revenues [15]. While in policy areas such as pensions, these measures were accompanied by structural reforms; this was not the case in healthcare which was,

**106**

Eu 28

**Table 1.**

*Source: Eurostat: National accounts and GDP online database.*

*GDP rates: percentage change on previous year.*

*General government gross debt in Italy: percentage of GDP.*


#### **Table 3.**

*Financing of the central funding for LEAs.*

1000 inhabitants; a redefinition, in a generally restrictive sense, of the criteria used to set the regional tariffs (linked to DRG-like systems), for inpatient and outpatient services provided to the NHS; general restrictions of the expenditure on purchases of goods and services; increasing revenues, mainly by increasing the copayments for citizens, although Regions have the possibility to make partially different choices.

These measures were added to those aimed at controlling staff expenditure in all public services [15], which are of particular significance due to the importance of human resources in the health sector. In the NHS there were main two types of measures addressed to public providers: measures aimed at gradually reducing the number of employees and others at containing wage and salaries.

In the first case, at the end of 2006, and thus before the start of the crisis, a cap for personnel expenditure in the NHS, which had to be equal to the 'corresponding amount of the year 2004 reduced by 1.4%', including costs for temporary employees and autonomous workers. This measure has been substantially confirmed, with some minor changes, until May 2019, when it was replaced by less restrictive constraints.

A predictable result of the cap and other similar measures was a slowdown and substantial stop in the staff hiring and turnover within the NHS healthcare organisations. Between 2008 and 2017, the staff of the NHS passed from 689,873 to 647,048 total employees, a drop of 42,825 employees (−6.2%; data taken from the Ministry of Economy and Finance online database). The decrease was highly significant, considering that the Italian healthcare service is understaffed compared with many European countries [1].

Staff hiring was reopened in 2017–2018; especially after that the new national NHS collective agreement signed in 2018 opened the possibility to hold extraordinary public competitions for the new recruitment of doctors, nurses and technical health personnel. These measures were confirmed by the stability law for 2019. However, the pace of recruitment seems inadequate to face the lack of healthcare staff within the NHS, which will become more serious in the next years considering the predictable wave of retirements connected to an ageing labour force, especially among doctors [18].

Furthermore, a second type of measures concerned the containment of wages for employees in the NHS, as well as independent professionals working for the NHS, starting from the general practitioners and paediatricians. After moderate wage increases in 2008–2009, national-level collective bargaining was suspended for 2 years, in 2010, for all 2,800,000 contractualised public employees, including NHS staff. The suspension was then extended until 2015, when a sentence of the Constitutional Court forced the government to restart the collective bargaining process in the public sector. A new national NHS collective agreement for the period of 2016–2018 was signed in May 2018, with modest pay increases. Collective negotiations at decentralised level was not frozen but was put under strict financial constraints, with the prohibition to exceed the amount of resources used in 2010. The overall effect of these provisions was to freeze the salaries of NHS employees for 8 years, substantially to the levels of 2010.

In addition to these measures, there were also specific measures addressing the Regions in conditions of high deficit in the health sector and therefore subjected to a recovery plan, which will be dealt in the second part of the article.

#### **4. Dynamics of public and private expenditure: out-of-pocket payments and occupational funds**

The overall effect of the austerity policies and public underfinancing policies has been a recalibration in the health expenditure levels, which were already lower

**109**

**Table 4.**

*Economic Crisis, Decentralisation and Health Inequalities: The Case of Italy*

diture amounted to 8.8% of the GDP (OECD database).

than the average values recorded in comparable continental and Northern European countries, and in line with the other countries of Southern Europe (in particular Spain and Portugal). In Italy, in 2015–2016, the total health expenditure in fact amounted to 8.9–9% of the GDP (+0.7–0.8% compared with 2007), two points (or more) below than in France, Germany and Sweden, which traditionally have expenditures higher than Italy, and also nearly a point less than in the UK, which has always been a very parsimonious country. In 2017–2018, the total health expen-

Also public (or government) health expenditure is lower than in the main continental and Northern European countries, in terms of both the share of the GDP and per capita expenditure (**Table 3**). Starting from a precrisis value of 6.3% (2007), the Italian government expenditure, GDP ratio did not grow even by half a percent in the following decade (6.6% in 2017 and 6.5% in 2018 estimation), despite the inevitable increase in demand for services with a steadily ageing population, which has the highest share of the over 60 age bracket in Europe (22.3% in 2017) and the highest median age in Europe along with Germany (45.9 in 2017, Eurostat database). Similarly, public expenditure per capita on health services increased by 18% from 2007 to 2018, a share much lower than in the main continental and Northern Europe

Italian trends in public expenditure on health are more similar to those of other Mediterranean European countries such as Portugal and Spain, although, from 2007 to 2016, the growth of expenditure per capita in Spain was certainly higher (23.3%). At the same time, the share of private health expenditure over the total expenditure on health, while diminishing in France, Germany and Sweden, increased in the UK, Italy and other Southern European countries (**Table 5**). In Italy, from 2007 to 2018, it shifted from 22.5 to 25.8% of the total health expenditure, therefore coming to represent more than a quarter of total health expenditure. This brought the level of private health expenditure closer to that of Spain. Highest ratios of private health expenditures, which should not be typical of NHS systems, are shared by other Mediterranean countries such as Portugal and Spain (and, of course, Greece where private health expenditures represent nearly 40% of total health expenditure).

The increase in private health expenditure, traditionally high, entails serious risks of worsening in social inequalities, in an era of economic crisis, especially because in Italy it is mainly constituted by out-of-pocket payments which, as it is well-known, emphasise the role of socioeconomic inequalities in service access. Between 2007

**Share of GDP (%) Per capita (US\$PPP) Growth of expenditure** 

**2000 2007 2018p 2000 2007 2018p 2007-2018p**

France 7.6 8.0 9.3 2119 2770 4141 33.1 Germany 7.7 7.5 9.5 2260 2809 5056 44.4 Sweden 6.3 6.6 9.3 1878 2647 4570 42.1 UK 4.7 6.1 7.5 1238 2111 3139 32.7 Italy 5.5 6.3 6.5 1474 2088 2545 18.0 Portugal 5.9 6.2 6.0 1127 1548 1902 18.6 Spain 4.9 5.7 6.2 1087 1795 2341 23.3

*p = provisional value. Source: OECD Health Care online database.*

*Levels of current public expenditure on healthcare.*

**per capita (%)**

*DOI: http://dx.doi.org/10.5772/intechopen.89006*

countries reported in **Table 4**.

#### *Economic Crisis, Decentralisation and Health Inequalities: The Case of Italy DOI: http://dx.doi.org/10.5772/intechopen.89006*

*Universal Health Coverage*

with many European countries [1].

for 8 years, substantially to the levels of 2010.

**and occupational funds**

among doctors [18].

1000 inhabitants; a redefinition, in a generally restrictive sense, of the criteria used to set the regional tariffs (linked to DRG-like systems), for inpatient and outpatient services provided to the NHS; general restrictions of the expenditure on purchases of goods and services; increasing revenues, mainly by increasing the copayments for citizens, although Regions have the possibility to make partially different choices. These measures were added to those aimed at controlling staff expenditure in all public services [15], which are of particular significance due to the importance of human resources in the health sector. In the NHS there were main two types of measures addressed to public providers: measures aimed at gradually reducing the

In the first case, at the end of 2006, and thus before the start of the crisis, a cap for personnel expenditure in the NHS, which had to be equal to the 'corresponding amount of the year 2004 reduced by 1.4%', including costs for temporary employees and autonomous workers. This measure has been substantially confirmed, with some minor changes, until May 2019, when it was replaced by less restrictive constraints. A predictable result of the cap and other similar measures was a slowdown and substantial stop in the staff hiring and turnover within the NHS healthcare organisations. Between 2008 and 2017, the staff of the NHS passed from 689,873 to 647,048 total employees, a drop of 42,825 employees (−6.2%; data taken from the Ministry of Economy and Finance online database). The decrease was highly significant, considering that the Italian healthcare service is understaffed compared

Staff hiring was reopened in 2017–2018; especially after that the new national NHS collective agreement signed in 2018 opened the possibility to hold extraordinary public competitions for the new recruitment of doctors, nurses and technical health personnel. These measures were confirmed by the stability law for 2019. However, the pace of recruitment seems inadequate to face the lack of healthcare staff within the NHS, which will become more serious in the next years considering the predictable wave of retirements connected to an ageing labour force, especially

Furthermore, a second type of measures concerned the containment of wages for employees in the NHS, as well as independent professionals working for the NHS, starting from the general practitioners and paediatricians. After moderate wage increases in 2008–2009, national-level collective bargaining was suspended for 2 years, in 2010, for all 2,800,000 contractualised public employees, including NHS staff. The suspension was then extended until 2015, when a sentence of the Constitutional Court forced the government to restart the collective bargaining process in the public sector. A new national NHS collective agreement for the period of 2016–2018 was signed in May 2018, with modest pay increases. Collective negotiations at decentralised level was not frozen but was put under strict financial constraints, with the prohibition to exceed the amount of resources used in 2010. The overall effect of these provisions was to freeze the salaries of NHS employees

In addition to these measures, there were also specific measures addressing the Regions in conditions of high deficit in the health sector and therefore subjected to a

**4. Dynamics of public and private expenditure: out-of-pocket payments** 

The overall effect of the austerity policies and public underfinancing policies has been a recalibration in the health expenditure levels, which were already lower

recovery plan, which will be dealt in the second part of the article.

number of employees and others at containing wage and salaries.

**108**

than the average values recorded in comparable continental and Northern European countries, and in line with the other countries of Southern Europe (in particular Spain and Portugal). In Italy, in 2015–2016, the total health expenditure in fact amounted to 8.9–9% of the GDP (+0.7–0.8% compared with 2007), two points (or more) below than in France, Germany and Sweden, which traditionally have expenditures higher than Italy, and also nearly a point less than in the UK, which has always been a very parsimonious country. In 2017–2018, the total health expenditure amounted to 8.8% of the GDP (OECD database).

Also public (or government) health expenditure is lower than in the main continental and Northern European countries, in terms of both the share of the GDP and per capita expenditure (**Table 3**). Starting from a precrisis value of 6.3% (2007), the Italian government expenditure, GDP ratio did not grow even by half a percent in the following decade (6.6% in 2017 and 6.5% in 2018 estimation), despite the inevitable increase in demand for services with a steadily ageing population, which has the highest share of the over 60 age bracket in Europe (22.3% in 2017) and the highest median age in Europe along with Germany (45.9 in 2017, Eurostat database). Similarly, public expenditure per capita on health services increased by 18% from 2007 to 2018, a share much lower than in the main continental and Northern Europe countries reported in **Table 4**.

Italian trends in public expenditure on health are more similar to those of other Mediterranean European countries such as Portugal and Spain, although, from 2007 to 2016, the growth of expenditure per capita in Spain was certainly higher (23.3%).

At the same time, the share of private health expenditure over the total expenditure on health, while diminishing in France, Germany and Sweden, increased in the UK, Italy and other Southern European countries (**Table 5**). In Italy, from 2007 to 2018, it shifted from 22.5 to 25.8% of the total health expenditure, therefore coming to represent more than a quarter of total health expenditure. This brought the level of private health expenditure closer to that of Spain. Highest ratios of private health expenditures, which should not be typical of NHS systems, are shared by other Mediterranean countries such as Portugal and Spain (and, of course, Greece where private health expenditures represent nearly 40% of total health expenditure).

The increase in private health expenditure, traditionally high, entails serious risks of worsening in social inequalities, in an era of economic crisis, especially because in Italy it is mainly constituted by out-of-pocket payments which, as it is well-known, emphasise the role of socioeconomic inequalities in service access. Between 2007


#### **Table 4.** *Levels of current public expenditure on healthcare.*

and 2014, the share of individuals reported unmet needs for medical examinations (because they were too expensive, because care facilities were too far away or because of waiting lists) for medical examinations shifted from 4.1 to 7.0%, highly concentrated in the share of population with the lowest income (elaborations by E. Pavolini on OECD health care online database). It is quite likely that the combination between cost-containment and retrenchment policies in the public sector and the increase in the role of private expenditure played an important role in determining this result.

However, an important part of the growth of private health expenditure in Italy during the crisis was due to the insurance component. In this regard, one of the most recent transformations that has taken place in Italy in relation to private health expenditure is the spread of occupational health funds for workers and their families, introduced or reintroduced from national collective bargaining or unilateral initiatives by employers (**Table 6**).

Although the occupational funds were almost non-existent in the 1990s, they have increased dramatically in the past decade, especially since the mid-2000s, reaching more than 10,000,000 people, around 33–35% of the total employees, in 2017. Most of the workers registered to an occupational scheme are employees (63% of total registered people), which mostly belong to the private sector, given that occupational schemes in healthcare are still nearly absent in the public sector.

The increased role of occupational healthcare funds represents a major challenge to the universalistic nature of the Italian NHS for three main reasons [19]: (a) they are increasingly financing core healthcare provision (especially diagnostics


#### **Table 5.**

*Private and out-of-pocket health expenditure in share of total health expenditure (%) (in brackets: outof-pocket health expenditure as % of total health expenditure).*


**111**

*Economic Crisis, Decentralisation and Health Inequalities: The Case of Italy*

and ambulatory care), which should be offered by the NHS, acting as a substitute for NHS services rather than completing or supplementing them; (b) access to occupational healthcare funds is profoundly affected by the employees' occupation and their position in the labour market (fixed-term vs. open-ended contracts, manual occupations vs. nonmanual occupations, unskilled occupations vs. skilled professions, etc.), and coverage is therefore rather unevenly distributed among workers and also in relation to the sector of employment; and (c) occupational schemes are concentrated among workers employed in big and medium-sized firms; this entails the creation of inequalities among those employed in firms of different sizes. Moreover, as medium and big firms are mainly located in the North of Italy, the spread of occupational funds brings serious risk to deepen the traditional differences existing in service access and quality between the North and the South

**5. The evolution of the governance of the NHS between the reassertion of the role of the State and the development of a differentiated** 

Unlike the oldest national health services, such as those of England or Sweden, the Italian NHS has always had a decentralised structure, in line with the Italian Constitution. In a first phase (1978–1992), the powers and responsibilities were divided among the State, Regions and local government. With the reforms of 1992– 1993 (Legislative Decrees No. 502/1992 and No. 517/1993), instead, the regionalisation of the NHS was introduced, together with its managerialisation [5, 20]. Regionalisation was then strengthened by the Constitutional reform introduced in 2001 and confirmed by the failures of subsequent attempts of Constitutional

According to current regulation, legislative powers are shared between Central

The balance of powers between state and regions that emerged from the regionalisation introduced during the 1990s and in 2001 required a permanent mechanism of negotiation and, possibly, cooperation between the State and the Regions to

On the one hand, since 2001 the central government has been *de facto* unable to implement institutional and organisational reforms without the consent and the involvement of regions. On the other hand, regions must respect a national regulative framework which imposes significant constraints on their possibility to introduce institutional changes within the regional healthcare systems. Therefore, concerted policy-making has been developing since 2000–2001. It has given rise to a series of 'agreements', 'pacts' or 'ententes' signed in the 'State, Regions and Local Governments Conference' (simply called State-Regions Conference) and then

State and Regions. As already mentioned, the State is in charge of defining the 'essential levels of healthcare', or LEAs, and has to guarantee regions the financial resources necessary for LEA provision. Regions and the two Autonomous Provinces of Trento and Bolzano have great freedom in organisation and management of their Regional Health Services. Starting from the second half of the 1990s, different 'regional healthcare models' emerged, characterised by regulatory structures marked by hierarchical integration, cooperation or competition between purchasers and service providers [2]. NHS regionalisation includes also a certain degree of fiscal autonomy, even if very restricted (see [21]), as well as the possibility of introducing copayments for drugs and outpatient services at

*DOI: http://dx.doi.org/10.5772/intechopen.89006*

of the country.

**regionalism**

reforms in 2006 and 2016.

regional level.

define national health policy.

converted into legislation by the Parliament.

#### **Table 6.**

*Registered people to occupational schemes: 2017.*

*Economic Crisis, Decentralisation and Health Inequalities: The Case of Italy DOI: http://dx.doi.org/10.5772/intechopen.89006*

*Universal Health Coverage*

eral initiatives by employers (**Table 6**).

and 2014, the share of individuals reported unmet needs for medical examinations (because they were too expensive, because care facilities were too far away or because of waiting lists) for medical examinations shifted from 4.1 to 7.0%, highly concentrated in the share of population with the lowest income (elaborations by E. Pavolini on OECD health care online database). It is quite likely that the combination between cost-containment and retrenchment policies in the public sector and the increase in the role of private expenditure played an important role in determining this result. However, an important part of the growth of private health expenditure in Italy during the crisis was due to the insurance component. In this regard, one of the most recent transformations that has taken place in Italy in relation to private health expenditure is the spread of occupational health funds for workers and their families, introduced or reintroduced from national collective bargaining or unilat-

Although the occupational funds were almost non-existent in the 1990s, they have increased dramatically in the past decade, especially since the mid-2000s, reaching more than 10,000,000 people, around 33–35% of the total employees, in 2017. Most of the workers registered to an occupational scheme are employees (63% of total registered people), which mostly belong to the private sector, given that occupational schemes in healthcare are still nearly absent in the public sector. The increased role of occupational healthcare funds represents a major challenge to the universalistic nature of the Italian NHS for three main reasons [19]: (a) they are increasingly financing core healthcare provision (especially diagnostics

France 22.9 (9.5) 16.6 (9.4pp) −6.3 (−0.1pp) Germany 24.9 (14.3) 15.5 (12.3) −9.4 (−2.0) Sweden 18.1 (16.9) 16.1 (14.8) −2.0 (-2.1) UK 18.3 (10.4) 20.5 (16.0pp) 2.2 (5.6pp) Italy 22.5 (21.5) 25.8 (23.1) 3.3 (1.8) Portugal 31.3 (25.7) 33.5 (27.4pp) 2.2 (1.9pp) Spain 27.3 (21.0) 29.5 (23.6pp) 2.2 (2.6pp)

**2007 2018p Diff 2018p-2007**

**Categories No. of registered people to occupational schemes %** Employees 6,692,000 63.0 Independent workers 1,062,239 10.0 Employee relatives 1,944,634 18.3 Independent workers relatives 216,070 2.0 Pensioners and relatives 500,966 4.7 Pensioner relatives 200,386 1.9 Total 10,616,847 100.0

*Private and out-of-pocket health expenditure in share of total health expenditure (%) (in brackets: out-*

*p = provisional value; pp = data referred to 2017. Source: OECD Health Care online database.*

*Source: GIMBE [17], elaborated from data by the Ministry of Health.*

*of-pocket health expenditure as % of total health expenditure).*

*Registered people to occupational schemes: 2017.*

**110**

**Table 6.**

**Table 5.**

and ambulatory care), which should be offered by the NHS, acting as a substitute for NHS services rather than completing or supplementing them; (b) access to occupational healthcare funds is profoundly affected by the employees' occupation and their position in the labour market (fixed-term vs. open-ended contracts, manual occupations vs. nonmanual occupations, unskilled occupations vs. skilled professions, etc.), and coverage is therefore rather unevenly distributed among workers and also in relation to the sector of employment; and (c) occupational schemes are concentrated among workers employed in big and medium-sized firms; this entails the creation of inequalities among those employed in firms of different sizes. Moreover, as medium and big firms are mainly located in the North of Italy, the spread of occupational funds brings serious risk to deepen the traditional differences existing in service access and quality between the North and the South of the country.

#### **5. The evolution of the governance of the NHS between the reassertion of the role of the State and the development of a differentiated regionalism**

Unlike the oldest national health services, such as those of England or Sweden, the Italian NHS has always had a decentralised structure, in line with the Italian Constitution. In a first phase (1978–1992), the powers and responsibilities were divided among the State, Regions and local government. With the reforms of 1992– 1993 (Legislative Decrees No. 502/1992 and No. 517/1993), instead, the regionalisation of the NHS was introduced, together with its managerialisation [5, 20]. Regionalisation was then strengthened by the Constitutional reform introduced in 2001 and confirmed by the failures of subsequent attempts of Constitutional reforms in 2006 and 2016.

According to current regulation, legislative powers are shared between Central State and Regions. As already mentioned, the State is in charge of defining the 'essential levels of healthcare', or LEAs, and has to guarantee regions the financial resources necessary for LEA provision. Regions and the two Autonomous Provinces of Trento and Bolzano have great freedom in organisation and management of their Regional Health Services. Starting from the second half of the 1990s, different 'regional healthcare models' emerged, characterised by regulatory structures marked by hierarchical integration, cooperation or competition between purchasers and service providers [2]. NHS regionalisation includes also a certain degree of fiscal autonomy, even if very restricted (see [21]), as well as the possibility of introducing copayments for drugs and outpatient services at regional level.

The balance of powers between state and regions that emerged from the regionalisation introduced during the 1990s and in 2001 required a permanent mechanism of negotiation and, possibly, cooperation between the State and the Regions to define national health policy.

On the one hand, since 2001 the central government has been *de facto* unable to implement institutional and organisational reforms without the consent and the involvement of regions. On the other hand, regions must respect a national regulative framework which imposes significant constraints on their possibility to introduce institutional changes within the regional healthcare systems. Therefore, concerted policy-making has been developing since 2000–2001. It has given rise to a series of 'agreements', 'pacts' or 'ententes' signed in the 'State, Regions and Local Governments Conference' (simply called State-Regions Conference) and then converted into legislation by the Parliament.

The State-Regions Conference includes the Prime Minister as President of the Conference, the Presidents (or Governors) of the Regions or other Ministers whenever matters related to areas of their competence are discussed. Instituted in 1988 and strengthened in 1997, in the first part of the 2000s, the Conference came to play a major role in national healthcare policy-making, representing the main institutional mechanism able to ensure close cooperation among Regions and permanent negotiation between those and the central government (see [22] for more details).

Although none of the regulatory changes had modified the above-described division of powers, the economic and financial crisis as well as political responses to the crisis weakened the role of the regions in national policy-making, in favour of greater importance of the role played by the central government, the Ministry of Economy and Finance (MEF) and, indirectly, by the European institutions. State-Region Conference has partially lost its centrality in policy-making, given that concerted policy-making has been increasingly substituted by unilateral decisionmaking by central government and supra-national institutions.

This shift became particularly evident after the explosion of the sovereign debt crisis of 2011–2012. The need to take urgent measures able to signal to international markets and the EU the willingness and ability of the national Government to bring the public debt under control have prompted approval of measures, contained in the laws of stability and austerity packages adopted by the Central Government, which in great part had not been agreed upon and basically not even discussed with the regions, Parliament and organised interests. The minimisation of room for discussion and negotiation was motivated by the lack of time and alternatives in the face of the commitments made with the EU and the need to reassure the markets. These dynamics did not occur only in Italy but were common to all the European countries most affected by the financial crisis and sovereign debt, namely, those of Southern Europe and, in a partially different form, Ireland [23–26].

The reassertion of the role of the State was enhanced by the economic crisis, but it had already started before 2007–2008. In the mid-2000s, many Regions showed to be unable to control health expenditure growth and contain regional deficits. In order to ensure compliance with the European Stability and Growth Pact, in 2005, the central government and Regions agreed on a multistep mechanism of regional expenditure monitoring and recovery plans in the case of excessive deficits. If a Region accumulates serious deficits and misses spending targets, the agreement provides for the activation of automatic mechanisms (like an increase in regional taxes) and the close supervision of regional expenditure policies by the MEF. Central government may appoint a commissioner in charge of NHS administration in that Region and impose specific measures to reduce deficits, thereby introducing severe limitations on regional autonomy.

To date, the recovery plan mechanism has been activated in 10 (out of 20) regions, and 5 of them have been subjected to administration by a commissioner. In 2019, seven regions are subject to a recovery plan; most of them entered the mechanism between 2007 and 2010. These regions include all Southern and Southern-Central Regions except the small Basilicata, while only two Northern Regions were forced to approve a recovery plan and were never commissioned.

Despite differences between individual cases, the recovery plan mechanism was largely effective in securing a debt reduction of the regions. The success was such as to cause the Government to introduce a control mechanism of deficits of individual NHS providers, bound to the presentation of plans, in 2015.

However, experience has shown that, once the plan procedures began, it was extremely difficult to abandon them. This was due not only to the presence of particularly demanding financial targets in years of economic crisis but also to the existence of objectives beyond purely economic aspects that impacted on quality and access

**113**

**6. Conclusions**

occupational groups.

*Economic Crisis, Decentralisation and Health Inequalities: The Case of Italy*

to services. In many cases these objectives were not easy to meet, considering that recovery plans inevitably required retrenchment policies which entailed severe cuts and other kind of restrictions in service provision. On this respect, this monitoring mechanism might have determined a worsening in some dimensions linked to access and service quality, widening the gap between Southern Regions which entered into the recovery plans and Northern Regions free from the plans and their constraints. From the point of view of the intergovernmental relations, the recovery plan mechanism severely restricted the autonomy of regional governments in the development of health policies. Central government and, in particular, the MEF not only exerted a penetrating supervision and monitoring of the plan implementations in the regions concerned but also, often, gained the right to exert a sort of veto, in the face of regional policies that involve increased expenditure. Although the formal division of powers between the levels of government has not changed over the past decade, regional decentralisation proved in fact to be much weakened in favour of an increase of the Central State's regulatory role, embodied by MEF rather than by

If Central and Southern-Central healthcare have been subjected to these strict forms of control during the years of crisis and until now, this has not been the case of the Northern and Central-Northern regions, except for two cases (Piedmont and Liguria). In most of these regions, the ability to maintain fiscal equilibrium or limited deficit has allowed them to consolidate the autonomy of regional health

Moreover, some of these regions (Emilia-Romagna, Lombardy and Veneto) have formally demanded 'further forms and conditions of autonomy' (Article 116, cl. 3, Italian Constitution), both in the health sector and in other policy sectors, which would make them more similar to the five Italian regions provided, from the 1950s,

After the successful consultative referendum held in Lombardy and Veneto on 22–23 October 2017, and the formal request of the Emilia-Romagna government between August and October 2017, a negotiating table was opened with the central government, according to the procedure laid down in Art. 116 of the Constitution. Although negotiations are still underway, with serious conflicts emerged between the two parties of the current coalition government, it is quite clear that the request of more autonomy should concern not only the management of resources but also regional tax capacity, so as to take a significant step towards a more complete accountability of the regions. One of the most delicate issue concerns the possibility to retain most of fiscal revenues collected within any single region, limiting the process of central redistribution. Given the very relevant differences in fiscal capacity between the North and the South of Italy, the potential effects of this change could

Economic and financial crises which severely hit Italy did not result into structural and fundamental changes in the NHS. However, it prompted or accelerated some processes which seriously risk to gradually change a universalist healthcare system into a more hybrid one. Retrenchment and austerity policies in the public, underfinanced NHS find some sort of compensation in the high level of private out-of-pocket expenditure and in the spread of occupational funds. As a consequence, traditional inequalities in access to healthcare services are deepening and seem bound to increase, exacerbating differences among socioeconomic and

policies, even in the presence of nationally determined austerity policies.

with a special autonomy for historical or ethnical reasons.

be highly detrimental for Southern Regions.

*DOI: http://dx.doi.org/10.5772/intechopen.89006*

the Ministry of Health [27, 28].

#### *Economic Crisis, Decentralisation and Health Inequalities: The Case of Italy DOI: http://dx.doi.org/10.5772/intechopen.89006*

*Universal Health Coverage*

The State-Regions Conference includes the Prime Minister as President of the Conference, the Presidents (or Governors) of the Regions or other Ministers whenever matters related to areas of their competence are discussed. Instituted in 1988 and strengthened in 1997, in the first part of the 2000s, the Conference came to play a major role in national healthcare policy-making, representing the main institutional mechanism able to ensure close cooperation among Regions and permanent negotiation between those and the central government (see [22] for more details). Although none of the regulatory changes had modified the above-described division of powers, the economic and financial crisis as well as political responses to the crisis weakened the role of the regions in national policy-making, in favour of greater importance of the role played by the central government, the Ministry of Economy and Finance (MEF) and, indirectly, by the European institutions. State-Region Conference has partially lost its centrality in policy-making, given that concerted policy-making has been increasingly substituted by unilateral decision-

This shift became particularly evident after the explosion of the sovereign debt crisis of 2011–2012. The need to take urgent measures able to signal to international markets and the EU the willingness and ability of the national Government to bring the public debt under control have prompted approval of measures, contained in the laws of stability and austerity packages adopted by the Central Government, which in great part had not been agreed upon and basically not even discussed with the regions, Parliament and organised interests. The minimisation of room for discussion and negotiation was motivated by the lack of time and alternatives in the face of the commitments made with the EU and the need to reassure the markets. These dynamics did not occur only in Italy but were common to all the European countries most affected by the financial crisis and sovereign debt, namely, those of

The reassertion of the role of the State was enhanced by the economic crisis, but it had already started before 2007–2008. In the mid-2000s, many Regions showed to be unable to control health expenditure growth and contain regional deficits. In order to ensure compliance with the European Stability and Growth Pact, in 2005, the central government and Regions agreed on a multistep mechanism of regional expenditure monitoring and recovery plans in the case of excessive deficits. If a Region accumulates serious deficits and misses spending targets, the agreement provides for the activation of automatic mechanisms (like an increase in regional taxes) and the close supervision of regional expenditure policies by the MEF. Central government may appoint a commissioner in charge of NHS administration in that Region and impose specific measures to reduce deficits, thereby

To date, the recovery plan mechanism has been activated in 10 (out of 20) regions, and 5 of them have been subjected to administration by a commissioner. In 2019, seven regions are subject to a recovery plan; most of them entered the mechanism between 2007 and 2010. These regions include all Southern and Southern-Central Regions except the small Basilicata, while only two Northern Regions were

Despite differences between individual cases, the recovery plan mechanism was largely effective in securing a debt reduction of the regions. The success was such as to cause the Government to introduce a control mechanism of deficits of individual

However, experience has shown that, once the plan procedures began, it was extremely difficult to abandon them. This was due not only to the presence of particularly demanding financial targets in years of economic crisis but also to the existence of objectives beyond purely economic aspects that impacted on quality and access

making by central government and supra-national institutions.

Southern Europe and, in a partially different form, Ireland [23–26].

introducing severe limitations on regional autonomy.

forced to approve a recovery plan and were never commissioned.

NHS providers, bound to the presentation of plans, in 2015.

**112**

to services. In many cases these objectives were not easy to meet, considering that recovery plans inevitably required retrenchment policies which entailed severe cuts and other kind of restrictions in service provision. On this respect, this monitoring mechanism might have determined a worsening in some dimensions linked to access and service quality, widening the gap between Southern Regions which entered into the recovery plans and Northern Regions free from the plans and their constraints.

From the point of view of the intergovernmental relations, the recovery plan mechanism severely restricted the autonomy of regional governments in the development of health policies. Central government and, in particular, the MEF not only exerted a penetrating supervision and monitoring of the plan implementations in the regions concerned but also, often, gained the right to exert a sort of veto, in the face of regional policies that involve increased expenditure. Although the formal division of powers between the levels of government has not changed over the past decade, regional decentralisation proved in fact to be much weakened in favour of an increase of the Central State's regulatory role, embodied by MEF rather than by the Ministry of Health [27, 28].

If Central and Southern-Central healthcare have been subjected to these strict forms of control during the years of crisis and until now, this has not been the case of the Northern and Central-Northern regions, except for two cases (Piedmont and Liguria). In most of these regions, the ability to maintain fiscal equilibrium or limited deficit has allowed them to consolidate the autonomy of regional health policies, even in the presence of nationally determined austerity policies.

Moreover, some of these regions (Emilia-Romagna, Lombardy and Veneto) have formally demanded 'further forms and conditions of autonomy' (Article 116, cl. 3, Italian Constitution), both in the health sector and in other policy sectors, which would make them more similar to the five Italian regions provided, from the 1950s, with a special autonomy for historical or ethnical reasons.

After the successful consultative referendum held in Lombardy and Veneto on 22–23 October 2017, and the formal request of the Emilia-Romagna government between August and October 2017, a negotiating table was opened with the central government, according to the procedure laid down in Art. 116 of the Constitution. Although negotiations are still underway, with serious conflicts emerged between the two parties of the current coalition government, it is quite clear that the request of more autonomy should concern not only the management of resources but also regional tax capacity, so as to take a significant step towards a more complete accountability of the regions. One of the most delicate issue concerns the possibility to retain most of fiscal revenues collected within any single region, limiting the process of central redistribution. Given the very relevant differences in fiscal capacity between the North and the South of Italy, the potential effects of this change could be highly detrimental for Southern Regions.

#### **6. Conclusions**

Economic and financial crises which severely hit Italy did not result into structural and fundamental changes in the NHS. However, it prompted or accelerated some processes which seriously risk to gradually change a universalist healthcare system into a more hybrid one. Retrenchment and austerity policies in the public, underfinanced NHS find some sort of compensation in the high level of private out-of-pocket expenditure and in the spread of occupational funds. As a consequence, traditional inequalities in access to healthcare services are deepening and seem bound to increase, exacerbating differences among socioeconomic and occupational groups.

#### *Universal Health Coverage*

Moreover, the trend to informal but substantial re-centralisation in national policy-making, with the reassertion of the role of the state in charge of playing the role of 'financial watchdog' of regional governments, is having different consequences for Northern and Southern Regions. The former was able to retain their autonomy, so that to develop health policies targeted to the needs of their citizens, while the ladder entered into a monitoring mechanism of their expenditure, which is giving significant results in financial terms but risk to worsen service access and quality.

So far, healthcare system 'hybridisation' [29] and the trend to 'differentiated federalism' [28] or 'differentiated autonomy' have occurred without any structural reforms, by means of imperceptible but progressive changes which, in terms of institutional change, may be qualified in terms of 'gradual transformation' [30, 31]. However, the formal request for constitutional change by three regions and related, current political conflicts, as well as the increasing complaints and also protests by doctors and healthcare experts on NHS underfinancing, emphasised by the media, might help promote an open debate on the future of the Italian NHS and health policy, which has been completely lacking so far.

#### **Author details**

Stefano Neri Department of Social and Political Sciences, University of Milan, Italy

\*Address all correspondence to: stefano.neri@unimi.it

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

**115**

*Economic Crisis, Decentralisation and Health Inequalities: The Case of Italy*

[9] Terraneo M. La salute negata. Le sfide dell'equità in prospettiva sociologica. Milano: Franco Angeli; 2018

[11] Mapelli V. Il sistema sanitario italiano. Bologna: Il Mulino; 2012 (new

[12] Pavolini E, Vicarelli G. Is decentralization good for your health? Transformations in the Italian NHS. Current Sociology.

[13] Toth F. How health care

Welfare. 2016;**3**:171-178

regionalisation in Italy is widening the North-South gap. Health Economics, Policy and Law. 2014;**9**(3):231-249

[14] Toth F. The Italian NHS, the public/ private sector mix and the disparities in access to healthcare. Global Social

[15] Bordogna L, Neri S. Austerity policies, social dialogue and public services, in Italian local government. Transfer: European Review of Labour and Research. 2014;**20**(3):357-371

[16] Ministero della Salute. Il

[17] GIMBE. 4° Rapporto sulla sostenibilità del Servizio Sanitario Nazionale. Fondazione GIMBE; 2019. Available from: http://www.

[18] Vicarelli G, Pavolini E. Health workforce governance in Italy. Health Policy. 2015;**119**(12):1606-1612

riaLea&menu=dati

rapportogimbe.it/

finanziamento del Servizio Sanitario Nazionale. 2019. Available from: http:// www.salute.gov.it/portale/temi/p2\_6.jsp ?id=4752&area=programmazioneSanita

2012;**60**(4):472-488

Roma. 2018

edition)

[10] Ministero della Salute. Monitoraggio dei LEA attraverso la cd. Griglia LEA. Metodologia e risultati dell'anno 2017.

*DOI: http://dx.doi.org/10.5772/intechopen.89006*

[1] Vicarelli G. Healthcare: Difficult paths of reform. In: Ascoli U, Pavolini E, editors. The Italian Welfare State in a European Perspective. Bristol: Policy

[2] Neri S. The evolution of regional

[3] OECD. Health at a Glance—OECD Indicators. Paris: OECD Publishing; 2017. Available from: http://www.oecd. org/health/health-systems/health-at-a-

[4] OECD. Italy: Country Health Profile 2017. Paris: OECD Publishing; 2017. Available from: http://www.oecd.org/fr/ italie/italy-country-health-profile-2017-

[5] Giarelli G. 1978-2918: quarant'anni dopo. Il Ssn tra definanziamento, aziendalizzazione e regionalizzazione. Autonomie Locali e Servizi Sociali.

[6] GIMBE. Il Servizio Sanitario Nazionale nelle classifiche

[7] OECD/EU. Health at a Glance: Europe 2018: State of Health in the EU Cycle. Paris: OECD Publishing; 2018. DOI: 10.1787/ health\_glance\_eur-2018-en

[8] Sarti S, Terraneo M, Tognetti

2017;**121**(3):307-314

Bordogna M. Poverty and private health expenditures in Italian households during the recent crisis. Health Policy.

internazionali. In: Report Osservatorio GIMBE 4/2018. Fondazione GIMBE; 2018. Available from: https://www. gimbe.org/pagine/1207/it/report-42018 il-ssn-nelle-classifiche-internazionali

Press; 2015. pp. 157-178

health services and the new governance of the NHS in Italy. In: Douglas A, Zoe B, editors. Health Studies: Economic, Management and Policy. Athens: Atiner; 2011.

**References**

pp. 269-282

glance-19991312.htm

9789264283428-en.htm

2017;**3**:455-482

*Economic Crisis, Decentralisation and Health Inequalities: The Case of Italy DOI: http://dx.doi.org/10.5772/intechopen.89006*

#### **References**

*Universal Health Coverage*

quality.

**114**

**Author details**

Department of Social and Political Sciences, University of Milan, Italy

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

Moreover, the trend to informal but substantial re-centralisation in national policy-making, with the reassertion of the role of the state in charge of playing the role of 'financial watchdog' of regional governments, is having different consequences for Northern and Southern Regions. The former was able to retain their autonomy, so that to develop health policies targeted to the needs of their citizens, while the ladder entered into a monitoring mechanism of their expenditure, which is giving significant results in financial terms but risk to worsen service access and

So far, healthcare system 'hybridisation' [29] and the trend to 'differentiated federalism' [28] or 'differentiated autonomy' have occurred without any structural reforms, by means of imperceptible but progressive changes which, in terms of institutional change, may be qualified in terms of 'gradual transformation' [30, 31]. However, the formal request for constitutional change by three regions and related, current political conflicts, as well as the increasing complaints and also protests by doctors and healthcare experts on NHS underfinancing, emphasised by the media, might help promote an open debate on the future of the Italian NHS and health

\*Address all correspondence to: stefano.neri@unimi.it

provided the original work is properly cited.

policy, which has been completely lacking so far.

Stefano Neri

[1] Vicarelli G. Healthcare: Difficult paths of reform. In: Ascoli U, Pavolini E, editors. The Italian Welfare State in a European Perspective. Bristol: Policy Press; 2015. pp. 157-178

[2] Neri S. The evolution of regional health services and the new governance of the NHS in Italy. In: Douglas A, Zoe B, editors. Health Studies: Economic, Management and Policy. Athens: Atiner; 2011. pp. 269-282

[3] OECD. Health at a Glance—OECD Indicators. Paris: OECD Publishing; 2017. Available from: http://www.oecd. org/health/health-systems/health-at-aglance-19991312.htm

[4] OECD. Italy: Country Health Profile 2017. Paris: OECD Publishing; 2017. Available from: http://www.oecd.org/fr/ italie/italy-country-health-profile-2017- 9789264283428-en.htm

[5] Giarelli G. 1978-2918: quarant'anni dopo. Il Ssn tra definanziamento, aziendalizzazione e regionalizzazione. Autonomie Locali e Servizi Sociali. 2017;**3**:455-482

[6] GIMBE. Il Servizio Sanitario Nazionale nelle classifiche internazionali. In: Report Osservatorio GIMBE 4/2018. Fondazione GIMBE; 2018. Available from: https://www. gimbe.org/pagine/1207/it/report-42018 il-ssn-nelle-classifiche-internazionali

[7] OECD/EU. Health at a Glance: Europe 2018: State of Health in the EU Cycle. Paris: OECD Publishing; 2018. DOI: 10.1787/ health\_glance\_eur-2018-en

[8] Sarti S, Terraneo M, Tognetti Bordogna M. Poverty and private health expenditures in Italian households during the recent crisis. Health Policy. 2017;**121**(3):307-314

[9] Terraneo M. La salute negata. Le sfide dell'equità in prospettiva sociologica. Milano: Franco Angeli; 2018

[10] Ministero della Salute. Monitoraggio dei LEA attraverso la cd. Griglia LEA. Metodologia e risultati dell'anno 2017. Roma. 2018

[11] Mapelli V. Il sistema sanitario italiano. Bologna: Il Mulino; 2012 (new edition)

[12] Pavolini E, Vicarelli G. Is decentralization good for your health? Transformations in the Italian NHS. Current Sociology. 2012;**60**(4):472-488

[13] Toth F. How health care regionalisation in Italy is widening the North-South gap. Health Economics, Policy and Law. 2014;**9**(3):231-249

[14] Toth F. The Italian NHS, the public/ private sector mix and the disparities in access to healthcare. Global Social Welfare. 2016;**3**:171-178

[15] Bordogna L, Neri S. Austerity policies, social dialogue and public services, in Italian local government. Transfer: European Review of Labour and Research. 2014;**20**(3):357-371

[16] Ministero della Salute. Il finanziamento del Servizio Sanitario Nazionale. 2019. Available from: http:// www.salute.gov.it/portale/temi/p2\_6.jsp ?id=4752&area=programmazioneSanita riaLea&menu=dati

[17] GIMBE. 4° Rapporto sulla sostenibilità del Servizio Sanitario Nazionale. Fondazione GIMBE; 2019. Available from: http://www. rapportogimbe.it/

[18] Vicarelli G, Pavolini E. Health workforce governance in Italy. Health Policy. 2015;**119**(12):1606-1612

[19] Arlotti M, Ascoli U, Pavolini E. Une transformation structurelle en cours dans le système de santè italien: les fonds de santé. In: Ferréol G, editor. Systèmes de santé et politique de soins: vers de nouveaux défis? Louvain-la-Neuve: EME; 2018. pp. 193-208

[20] France G, Taroni F. The evolution of health-policy making in Italy. Journal of Health Politics, Policy and Law. 2005;**30**(1-2):69-188

[21] Bordignon M, Mapelli V, Turati G. Can we fit a square object in a round hole? Fiscal federalism and national health service in the Italian system of governments. In: ISAE, Annual Report on Monitoring Italy, Rome. 2002. pp. 37-125

[22] Maino F, Neri S. Explaining welfare reforms in Italy between economy and politics: External constraints and endogenous dynamics. Social Policy & Administration. 2011;**45**(4):445-464

[23] Asensio M, Popic T. Portuguese healthcare reforms in the context of crisis: External pressure or domestic choice? Social Policy & Administration. 2019;**1**:1-15. Available from: https:// onlinelibrary.wiley.com/doi/ epdf/10.1111/spol.12480

[24] Pavolini E, Guillén AM, editors. Health Care Systems in Europe Under Austerity: Institutional Reforms and Performance. Basingstoke: Palgrave; 2013

[25] Pavolini E, Lèon M, Guillén AM, Ranci C. From austerity to permanent strain? Comparative European Politics. 2015;**13**(1):56-76

[26] Sotiropoulos DA. Southern European governments and public bureaucracies in the context of economic crisis. European Journal of Social Security. 2015;(2):226-245

[27] Frisina-Doëtter L, Neri S. Redéfinir le rôle de l'État dans le soins de santé: une analyse comparative de l'Italie et des États-Unis. In: Ferréol G, editor. Systèmes de santé et politiques de soins: vers de noveaux défis? Louvain-la Neuve: EME Éditions; 2018. pp. 175-191

[28] Frisina-Doëtter L, Neri S. Redefining the state in health care policy in Italy and the United States. European Policy Analysis. 2018;**4**:234-254

[29] Rothgang H, Cacace M, Frisina L, Grimmeisen S, Schmid A, Wendt C. The State and Healthcare: Comparing OECD Countries. Houndmills: Palgrave Macmillan; 2010

[30] Streeck W, Thelen K, editors. Beyond Continuity. Institutional Change in Advanced Political Economies. Oxford: Oxford University Press; 2005

[31] Neri S. The Italian NHS after the economic crisis: From decentralization to differentiated federalism. e-cadernos CES. forthcoming

*Universal Health Coverage*

2005;**30**(1-2):69-188

Rome. 2002. pp. 37-125

[21] Bordignon M, Mapelli V, Turati G. Can we fit a square object in a round hole? Fiscal federalism and national health service in the Italian system of governments. In: ISAE, Annual Report on Monitoring Italy,

[19] Arlotti M, Ascoli U, Pavolini E. Une transformation structurelle en cours dans le système de santè italien: les fonds de santé. In: Ferréol G, editor. Systèmes de santé et politique de soins: vers de nouveaux défis? Louvain-la-Neuve: EME; 2018. pp. 193-208

[27] Frisina-Doëtter L, Neri S. Redéfinir le rôle de l'État dans le soins de santé: une analyse comparative de l'Italie et des États-Unis. In: Ferréol G, editor. Systèmes de santé et politiques de soins: vers de noveaux défis? Louvain-la Neuve: EME Éditions; 2018. pp. 175-191

Redefining the state in health care policy in Italy and the United States. European

[29] Rothgang H, Cacace M, Frisina L, Grimmeisen S, Schmid A, Wendt C. The State and Healthcare: Comparing OECD Countries. Houndmills: Palgrave

[28] Frisina-Doëtter L, Neri S.

Policy Analysis. 2018;**4**:234-254

[30] Streeck W, Thelen K, editors. Beyond Continuity. Institutional Change in Advanced Political

Economies. Oxford: Oxford University

[31] Neri S. The Italian NHS after the economic crisis: From decentralization to differentiated federalism. e-cadernos

Macmillan; 2010

Press; 2005

CES. forthcoming

[20] France G, Taroni F. The evolution of health-policy making in Italy. Journal of Health Politics, Policy and Law.

[22] Maino F, Neri S. Explaining welfare reforms in Italy between economy and politics: External constraints and endogenous dynamics. Social Policy & Administration. 2011;**45**(4):445-464

[23] Asensio M, Popic T. Portuguese healthcare reforms in the context of crisis: External pressure or domestic choice? Social Policy & Administration. 2019;**1**:1-15. Available from: https:// onlinelibrary.wiley.com/doi/ epdf/10.1111/spol.12480

[24] Pavolini E, Guillén AM, editors. Health Care Systems in Europe Under Austerity: Institutional Reforms and Performance. Basingstoke: Palgrave;

[25] Pavolini E, Lèon M, Guillén AM, Ranci C. From austerity to permanent strain? Comparative European Politics.

[26] Sotiropoulos DA. Southern European governments and public bureaucracies in the context of economic crisis. European Journal of Social Security. 2015;(2):226-245

**116**

2013

2015;**13**(1):56-76

*Edited by Aida Isabel Tavares*

The chapters in this book contribute to the wide discussion on universal health coverage. The variety of topics discussed here confirms the importance of UHC for academics and health professionals and also the controversies and challenges of its implementation.I invite you to read the book and be involved in the discussions around the goals of universal health coverage.

Published in London, UK © 2019 IntechOpen © utah778 / iStock

Universal Health Coverage

Universal Health Coverage

*Edited by Aida Isabel Tavares*