Essential treatments, the Ministry of Health's report cards for 2021 draw a merciless picture: only 14 regions have been promoted, Emilia-Romagna in the lead. In the South only Abruzzo, Basilicata and Puglia. This enormous North-South gap in healthcare seems to be unable to be filled any longer and the Calderoli bill on differentiated autonomy risks crystallizing a painful situation for citizens.
Lep and Leah
The Ddl provides that the subjects for which essential levels of performance (LEP) are necessary cannot be transferred from the State to the Regions before the very definition of the LEP, in order to guarantee a minimum level of performance throughout the national territory, avoiding that the transfer of skills to the richer Northern Regions determines a worsening of services for the citizens of the South. However, a few days ago the Committee for the identification of the LEP - states Nino Cartabellottapresident of the Gimbe Foundation - "suggested a dangerous shortcut for healthcare, for which it would not be necessary to define the LEPs as the Essential Levels of Assistance (LEA) already exist. LEAs which, despite their definition in 2001, their annual monitoring and the application of repayment plans and commissioners, in fact are not enforceable uniformly throughout the national territory, with large inequalities between North and South".
A gap that will increase with autonomy
A gap that will inevitably increase if greater autonomy is granted to the richest Northern Regions, which is why the Gimbe Foundation has requested in the Constitutional Affairs Commission of the Senate to remove healthcare from the subjects on which the Regions can request greater autonomy.
Following the recent publication of the "Monitoring of the LEA through the New Guarantee System" by the Ministry of Health, the GIMBE Foundation - explains the President - "carried out some analyzes both to estimate the extent of the current North-South divide in guaranteeing the constitutional right to health protection and the consequent risks of this "amnesty" proposed by the LEP Committee, as well as to assess the resilience and recovery capacity of the regional health services in the second year of the pandemic".
Ministry report card
Every year the Ministry of Health evaluates the provision of the LEA, i.e. the health services that the Regions must guarantee free of charge or upon payment of the co-payment. "It is a real "report card" for regional health services - says Cartabellotta - which identifies which Regions are promoted (compliant), therefore worthy of accessing the share of reward funding, and which rejected (defaulting) ". The defaulting Regions are subjected to the Repayment Plans, which provide for specific support from the Ministry of Health, which in the most critical situations can go as far as the commissioner.
The 22 new indicators
Since 2020, the "LEA Grid" has been replaced by 22 CORE indicators of the New Guarantee System (NSG), divided into three areas: collective prevention and public health, district assistance and hospital assistance. In each area the Regions can obtain a score between 0 and 100 and are considered compliant if they reach at least 60 points in all three areas; on the other hand, if the score is less than 60 even in just one area, the Region is in default. "Considering that 2021, like 2020, was marked by the pandemic emergency - the president specifies - the monitoring of the disbursement of the LEAs was carried out by the Ministry of Health only for evaluation and information purposes, with no impact on the reward quota".
LEA 2021 fulfillments
Compared to 2020, the Regions complying in 2021 rise from 11 to 14: Abruzzo, Basilicata, Emilia-Romagna, Friuli Venezia Giulia, Lazio, Liguria, Lombardy, Marche, Autonomous Province of Trento, Piedmont, Puglia, Tuscany, Umbria, Veneto. In particular, from 2020 to 2021 three Regions become compliant: Abruzzo, Basilicata and Liguria. 7 Regions remain in default: Campania, Molise, the Autonomous Province of Bolzano and Sicily with an insufficient score in only one area; Sardinia with an insufficient score in two areas; Calabria and Valle D'Aosta insufficient in all three areas (table 1). "The new "report card" - comments the president - also confirms the North-South gap for 2021, given that only Abruzzo, Puglia and Basilicata are among the 14 compliant Regions, moreover with the lowest scores among the "promoted" ones".
The Gimbe ranking
Considering that the Ministry of Health does not summarize the assessment of LEA obligations in a single score, the Gimbe Foundation has drawn up a ranking of Regions and Autonomous Provinces by adding up the scores obtained in the three areas, reporting the results in descending order divided into quartiles. "With respect to the status of compliant or defaulting Region - comments Cartabellotta - the total score further emphasizes the North-South gap: in fact, in the first 10 places there are 6 Regions from the North, 4 from the Center and none from the South, while at the bottom of the ranking there are, with the exception of Valle D'Aosta, only Southern Regions".
Gap 2020-2021 on three macro-levels
The Gimbe Foundation analyzed the differences between the 2020 and 2021 obligations, in order to evaluate the gradual recovery of the disbursement of the LEA after the outbreak of the pandemic by measuring the total scores of the Regions and the national performances on the three macro-levels of assistance. With the exception of Sardinia and Valle d'Aosta which in 2021 worsened their performances, in all the other Regions after the 2020 "stress test", the LEA scores increased, albeit in a different way. In Basilicata, Liguria, Lombardy and Calabria by over 30 points; in the Autonomous Province of Bolzano, Molise, Abruzzo, Campania between 20 and 30 points; in Umbria, Tuscany, Friuli Venezia Giulia and Marche between 10 and 19 points; in Piedmont, Lazio, the Autonomous Province of Trento, Sicily, Emilia-Romagna, Veneto and Puglia by less than 10 points (table 3). "These data - comments the President - document on the one hand, the clear recovery of some Regions (Lombardy, Liguria) hit in 2020 very violently by the first wave; on the other, the partial recovery of numerous defaulting Regions in 2020, almost all in the Center-South (Abruzzo, Basilicata, Calabria, Campania, Molise, the Autonomous Province of Bolzano), of which however only Abruzzo and Basilicata become compliant in 2021 ".
With regard to the impact of the pandemic on the three macro-levels of assistance, considering the whole national territory, in 2021 there was a marked improvement in the prevention area (+159 points) and in the hospital area (+135 points); on the contrary, the district area in 2021 shows a slight deterioration (-16 points). "The marked improvement in the prevention area - explains the President - is not sufficient to make up for the collapse (-263 points) recorded between 2019 and 2020 both due to the low investments in this area and because the already scarce personnel in the prevention departments have been employed at the forefront of the vaccination campaign"
North-South, a structural gap
"The monitoring of the Ministry of Health 2021 - concludes Cartabellotta - confirms the structural gap between North and South precisely at the moment in which the LEP Committee believes that in the field of health it is not necessary to define the LEPs, given the presence of the LEAs. This proposal suggests a dangerous shortcut for the greater autonomy in health, given that the Calderoli bill remains very vague on the financing as well as on the guarantee of the LEPs according to the provisions of the Constitution. Considering that our analyzes on the enforceability of the LEAs also confirm for the year 2021 a huge North-South gap, it is clear that without defining, financing and guaranteeing the LEP, the major autonomies in health will legally legitimize this fracture, compromising the equality of citizens in the face of the constitutional right to health protection and delivering the coup de grace to the National Health Service ".