Intergovernmental relations and Long Term Care reforms: lessons from the Italian case.

The article aims at analysing the reasons why Italy failed to reform Long Term Care (LTC) policies, focusing on an aspect which has been overlooked: the interplay between LTC policies and the intergovernmental multilevel relationships. In the Italian LTC system, the main central intervention has been the regularisation of migrant care work, while the automatic growth of the cash benefits has accompanied the care needs evolution. Therefore the only institutional change has been a "gradual transformation". The causes of the failure to reform LTC have been mainly related to a strong fragmentation of the policy field, the existence of a universalistic cash benefit, the fiscal constraint. We argue that a further obstacle to reform LTC policies has been the weak and uncertain legislative framework of federalism. The uncertainty on the allocation and distribution of resources and the delay to apply the equalisation mechanism based on needs engendered a lame federalism that contributed to hindering welfare innovations and to increasing the institutional fragmentation. The analysis is partly consistent with previous literature, although it places less emphasis on the role of the constituencies and the scarcity of resources in influencing decisions, focusing more on the implications of the failure to fully realise the federalist reform. This focus shows that to implement institutional change in the welfare system, it is important to take into account the features of the federal governance, the intergovernmental relations, and to address the challenges that are connected to them.

Governing decentralization in health care under tough budget constraint: what can we learn from the Italian experience?

In many European countries, since the World War II, there has been a trend towards decentralization of health policy to lower levels of governments, while more recently there have been re-centralization processes. Whether re-centralization will be the new paradigm of European health policy or not is difficult to say. In the Italian National Health Service (SSN) decentralization raised two related questions that might be interesting for the international debate on decentralization in health care: (a) what sort of regulatory framework and institutional balances are required to govern decentralization in health care in a heterogeneous country under tough budget constraints? (b) how can it be ensured that the most advanced parts of the country remain committed to solidarity, supporting the weakest ones? To address these questions this article describes the recent trends in SSN funding and expenditure, it reviews the strategy adopted by the Italian government for governing the decentralization process and discusses the findings to draw policy conclusions. The main lessons emerging from this experience are that: (1) when the differences in administrative and policy skills, in socio-economic standards and social capital are wide, decentralization may lead to undesirable divergent evolution paths; (2) even in decentralized systems, the role of the Central government can be very important to contain health expenditure; (3) a strong governance of the Central government may help and not hinder the enforcement of decentralization; and (4) supporting the weakest Regions and maintaining inter-regional solidarity is hard but possible. In Italy, despite an increasing role of the Central government in steering the SSN, the pattern of regional decentralization of health sector decision making does not seem at risk. Nevertheless, the Italian case confirms the complexity of decentralization and re-centralization processes that sometimes can be paradoxically reinforcing each other.

[Implementation of an emergency clinical pathway for ST-elevation myocardial infarction in the Lazio Region: results of a pilot study]. / Implementazione di un percorso clinico-assistenziale per la gestione dei pazienti con infarto miocardico con sopraslivellamento del tratto ST nella rete dell'emergenza del Lazio: risultati di uno studio pilota.

BACKGROUND: Timely reperfusion therapies (primary angioplasty and pre-hospital thrombolysis) remain a key component in improving the survival of patients with ST-segment elevation myocardial infarction (STEMI). The Lazio Region emergency organization has a complex mixed logistic (the large city of Rome, presence of complex orography), therefore the use of telemedicine technologies by the emergency medical system (EMS) is mandatory. Emergency clinical pathways (ECP) for the management of STEMI patients were designed, focusing on early pre-hospital diagnosis and best appropriate treatment through the ECG transmission and teleconsultation among EMS and cardiologists in coronary care units (CCU). METHODS: To evaluate the effectiveness of ECP-STEMI in the current practice, a prospective observational cohort study of ambulance-transported patients with cardiovascular symptoms was conducted in a selected area of the Lazio Region during a 6-month period. The implementation of the ECP was carried out by educational activities for the EMS personnel based on the "experiential learning" methods. RESULTS: From October 2005 to March 2006, 287 patients were enrolled in the study and a pre-hospital ECG was performed in 66% of them. One hundred and fifty-two patients were referred to hospital and only 34 had discharged diagnosis of acute myocardial infarction, of whom 23 were STEMI. In the 34 acute myocardial infarction patients the medium time from "call to the EMS" to "arrival to the hospital" was 41 min (range 29-63 min) and 3 had their ECG telematically transmitted from the ambulance to the CCU. All of these cases were STEMI. Twenty-eight acute myocardial infarctions were discharged alive, 2 were transferred in other hospitals, 4 died. No patients received pre-hospital thrombolysis. Prior to the ECP implementation the ECG for STEMI patients has never been transmitted by EMS to the CCU in the Lazio Region. CONCLUSIONS: Our study suggests that adherence to ECP improved the appropriateness of STEMI patient referral and treatment in the CCU in the Lazio Region. The EMS personnel, during the study, showed a high interest in the protocol trying to change their current practice. The Regional Administration plans to expand the utilization of ECP to all regional emergency network (EMS and Emergency Departments) and to improve its use.