Chapter 2

educe the gap (although not eliminate it) but only if regional rationalisation actions prove
to be effective;
• Actions are foreseen for making citizens more responsible for health care costs; the
concept may be agreed in principle, but there will be questionable equity effects from the
introduction of lump-sum prescription charges;
• The most questionable aspect is the institutional framework indicated by the manoeuvre,
which depicts a kind of “immature federalism”: on one side, the Budget Act is required
to approve Regional choices that have already been made (by the most virtuous
Regions) and, on the other side, to “impose” from above difficult or unpopular choices
(mainly on the Regions in major trouble);
■ The strictly central functions, such as supervision of quality and rights, are generally
referred to other regulations: but it would be preferable to avoid separating them from the
Budget Act since this would certainly render interventions less compulsory;
• Actions aimed at efficiency recovery substantially remain obscure in their contents and
substantially entrusted to the Regions, but with little effective incentive to responsibility,
because of the incompleteness of fiscal federalism;
• The age-old problem of attributing responsibility for the deficits is predicted to persist
(especially if the revenue coming from co-payments should prove to be below to what
was planned), with the consequent delays in payments to creditors;
■ International experience demonstrates that even the administration of deficits is a
management issue and that it is inefficient to add the implicit costs deriving from delays
in payments to failures in programming;
• Public expenditure has a multiplicative effect on total health care expenditure (public
plus private), attributable to service duplication mechanisms;
• Even the composition of the expenditures (between services supplied by public and private
provider) does not seem neutral; although limited to the centre-south we observe
an inefficient programming of the public-private relationship, leading to inappropriate
costs;
• Expenditure (obviously) is also growing due to the effects of economic development
and ageing;
• Total health care expenditure in 2007 should be between 8,2% and 8,3% of GDP, with
an increment of the public share; we foresee only a slight decrease in private expenditure,
due to the effect of more co-payment charges;
• The passage from control of expenditure to control of system rationalisation calls for
the unravelling of financial and efficiency elements: pressure to obtain savings in the
short term may explain the “neo-centralism” phenomena, but there is a lack of evidence
that, in the medium-long term, the institutional set up that is created will prove to be efficient;
• Sector policies based on “generic” actions seem to herald limited results, or even distorted
ones; this is the case for the pharmaceutical expenditure ceiling and for indications
regarding reduction of hospital capacity - which does not necessarily determine cost
reductions;
• The problem of pharmaceuticals essentially seems that of inappropriate prescription,
[35]
CEIS Health Report 2006