Chapter 2

CEIS Health Report 2006
If, therefore, minute regulation of patient payments at the government level is institutionally
questionable, it would be more desirable to address the topic of exemptions: for the
weakest categories they may be considered a right of citizenship. Instead, paradoxically,
they are actually subject to autonomous Regional decisions and, at present, these last
show rather large variations.
One explanation for the inversion of roles and the persistence of a certain institutional
confusion, can be attributed to the lack of full fiscal federalism, that would make the
Regions definitively economically responsible.
One has the feeling that the Regions in some way “use” the central government level to
“validate” their own decisions (in the case of the more active and often more virtuous
Regions) or to get advice on (or be compelled to take) the rationalization road (in the case
of the least efficient Regions).
This previous observation provides justification for the idea of an “immature” federalism,
the risk in which is simple displacement of the institutional conflict to the level of regional
sharing of resources, leaving the Budget Act with merely the role of setting the conditions
for addressing ex post the thorny question of responsibility for the deficit.
In the presence of a more mature federalism, one could expect a Budget Act to refrain
from setting modalities for restoring equilibrium to regional budgets, rather moving the
focus to monitoring and advice. One could object that it is not the role of a Budget Act
to set criteria for the quality and/or equity of health care provision, but international experience
demonstrates that complete de-linkage of such functions from financial leverage
makes central action at least partially ineffective. At the very least, one should imagine
definition of a system of incentives to pursue improvements to quality, which is the philosophy
of Clinical Governance, in Italy often cited inappropriately or even in a distorted
version.
In short, it would be desirable for the central government to adopt a policy of pay per
performance, thus providing an incentive for Regions to be efficient, effective (ensuring
good quality) and equitable, leaving the task of selecting modalities of implementation to
local responsibility.
This does not exclude that additional attention may be given to support Regions in the
most critical situations, as the present Budget Act have done, with the additional fund of
€ 1 billion.
That the ultimate aim must be to provide incentives for efficient, effective and fair behaviour
– if confirmation were needed – is made evident by the close relationship that the
public sector’s policies, including in expenditure, have with total health expenditure and
hence with private health expenditure, that is with household budgets.
The evolution of total health expenditure (see chapter 1.2, Polistena, Ratti, Spandonaro)
depends on economic growth factors and demographic changes, but is not exempt from
impacts attributable to institutional factors.
Specifically, the Polistena, Ratti and Spandonaro model indicates a multiplicative effect
of public expenditure on total expenditure: it could be partly attributed to duplication of
functions and partly to an inertial tendency of public expenditure to come into line with
its funding. This last finding in some way “justifies” the historical tendency (in the process
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