Until a few months ago the healthcare system in Lombardy, Italy’s wealthiest region, was widely admired. The system was described as the second most efficient in the world, with an annual turnover of €7.8 billion. Thousands of people from Italy and beyond flocked to its hospitals each year to avail themselves of its doctors and pioneering medical research. “Be healthy,” read an online brochure for the region, “come to Lombardy.”
When an outbreak of a new coronavirus in China was reported in January, public officials were confident in the system’s capacity to respond. “Don’t worry yourselves,” said the Prime Minister, Giuseppe Conte, on 3 February. “There’s no point in predicting an epidemic or pandemic, because the system is ready for every emergency.”
It was not ready. The coronavirus swept across Italy less than a month later, hitting Lombardy particularly hard. The region became front-page news in all the world’s newspapers as military trucks were required to manage the bodies from the hospitals, funerals were carried out without the bereaved, and medical staff compared the situation to “a world war“.
At time of writing, 66,971 people have been infected in Lombardy, of whom 11,851 have died. The region accounts for less than 20 per cent of Italy’s population, but 51 per cent of the country’s Covid-19 fatalities. The mortality rate from Covid-19 in Lombardy is around 18 per cent, three times that of neighbouring Veneto.
A number of factors have been blamed for Lombardy’s fate. A small Lombard town, Codogno, was the site of one of the first confirmed cases, giving the region less time to prepare a response than others. A football match played between Valencia CF and Bergamo-based team Atalanta at Milan’s San Siro stadium on 19 February became a so-called “super spreader” event, dispersing some 40,000 attendees throughout Italy and Spain, many of whom were infected.
Lombardy also has one of the densest populations of any Italian region, with an average of 420 inhabitants per square kilometre, compared to a national average of 206. It also, prior to the lockdown, had some of the most polluted air in Europe.
Nevertheless, the disparity with Veneto, which fared similarly badly at the beginning but was able to manage the crisis effectively and bring its mortality rate down, has prompted doctors in Italy to ask how Lombardy’s supposedly world-class healthcare system could have collapsed quite so catastrophically.
Doctors pin much of the blame on Italy’s widespread “public-private” healthcare system, in which private and public clinics compete for taxpayers’ money. The system came into play in 1997, when Rome opted to decentralise the Italian healthcare system and give regions more autonomy.
While Rome would still determine the budgets of the individual regions, they would be largely free to use the money as they pleased. Most regions continued to give preference to public hospitals, yet successive governments in Lombardy — first Berlusconi’s Forza Italia in 1997, then Matteo Salvini’s Lega Nord after the 2008 financial crash — chose to pit the two sectors against one another, withholding funds from those who fell below certain thresholds, believing this would spur efficiency.
Inevitably, the system skewed in favour of the private sector. Patients were eligible for care in either private or public facilities, with paying patients receiving certain privileges, like skipping long waiting lists. That meant private clinics had the best of both worlds: they could receive insured patients and also uninsured patients, foisting the burden of the free treatments on the taxpayer, at a higher cost.
Privatisation boomed: between 2010 and 2020, the share of public funds captured by private facilities went up from around 30 per cent to 50 per cent. (The latter figure is from Northern League senator Lucia Borgonzoni; others suggest it is closer to 40 percent.) Meanwhile, public facilities waned: between 2000 and 2017, for example, publicly funded “assistance” services — psychiatric, palliative care, and so on — decreased from 466 to 257, while the same services in the private sector doubled in number. The private sector also suffered far less from the dramatic effects of austerity, reporting only half the losses incurred by the public sector.
(The system was initially overseen by the region’s then-president Roberto Formigoni, a former vice-president of the European Parliament and close ally of Silvio Berlusconi. Formigoni’s career has been dogged by accusations of corruption: in 2012, he was alleged to have enlisted the Calabrian mafia to rig an election, and more recently he was jailed for taking bribes from a healthcare foundation.)
What followed was a race to the bottom, with both public and private facilities adapting their priorities to serve their financial needs, which had become increasingly dire in the years of austerity. Public hospitals were forced to compete against rivals that offered “customer first” patient experiences — better bedlinen, better food, more in-ward entertainment — over the less market-friendly considerations of community healthcare.
The public sector soon began to adjust its own priorities accordingly, says Gino Strada, the founder of Emergency, a Milan-based NGO critical of private healthcare. Things like home care — expensive, difficult and not financially rewarding to provide — went by the wayside, and the goal became simply to get people into hospitals, which had become all-purpose “centres of excellence”, says Rafaella Sadun, a professor at Harvard Business School who co-wrote a detailed post-mortem on the system’s failings.
Indeed, the healthcare system was scarcely built for the community at all, with at least 10 percent of patients coming from other regions.
Consider how local healthcare services were affected. Pietro Brambillasca, an anesthesiologist at Papa Giovanni XXIII, a large hospital in Bergamo, says keeping people out of hospital is crucial to limiting an epidemic. Local doctors, for example, can screen people for Covid-19, and treat those with mild symptoms —“checking for proper isolation, nutrition, oxygen, treating fever” — and only sending them to hospital when necessary.
But years of “patient-focused” care had depleted those vital local care services, says Brambillasca. In Lombardy, patients often don’t bother with general practitioners at all, he says, and typically go straight to hospital whatever the illness. Brambillasca says he’s often seen long queues outside the emergency rooms in Bergamo, where people presented with ailments as trivial as “footache.”
Coupled with a poorly conceived testing strategy that required only the very sick and their closest contacts to be tested — ignoring the lessons learned from the town of Vo’, which demonstrated Covid’s high rate of asymptomatic transmission — Lombardy’s underfunded community healthcare services could do little to address the rapidly growing number of infections, while those with symptoms headed straight to hospital.
That had huge knock-on effects, the infection was able to spread rapidly through hospitals, undetected. This was how the outbreak in Bergamo, Lombardy’s worst hit city, began: when dozens of people exhibiting Covid-19 symptoms rushed straight to a suburban hospital, they were turned back and sent home, only to then infect their communities.
Even once the outbreak was spreading rapidly, private hospitals had no obligation to share the burden, despite having captured a share of the public health budget. It was weeks later, on 17 March, that the Italian government issued the Cura Italia decree and began forcibly requisitioning private hospitals. However, the decree also stated that private healthcare providers would be compenstated for the full value of their services, meaning that tax payers would pay.
And in all but two metrics, accommodating “long-term patients” and “rehabilitation”, the private hospitals’ capacity to contribute to the response was minimal. They were, indeed, used to leaving such things to the public hospitals. Of 5,300 intensive care beds, just 800 were in private hospitals.
As the number of acute patients grew, the effects of the market on the public sector also became evident. The number of beds available in public hospitals had decreased from 45,630 to 20,838 between 1995 and 2018, and the number available in private hospitals remained insignificant, despite having jumped in that period from 10,602 to 13,155, according to forthcoming research cited by Maria Elisa Sartor, a professor at the University of Milan. Acute care beds, too, were hard to come by, and Lombardy compares unflatteringly with similar regions: in Veneto, there were 10 beds per 100,000 citizens; in Lombardy, 8.5.
Masks, gloves and ventilators were also in short supply, according to the Ordini di Medici, a prominent medical council which recently wrote an open letter criticising Italy’s response to the outbreak.
Stefano Merigliano, the dean of the University of Padua School of Medicine, says the first priority when dealing with a widespread infectious disease “is [to] protect the hospitals”. Instead, he told me, the overburdened public hospitals in Lombardy “closed all the patients inside, causing two infected people to become 500”.
Regular patients in the beleaguered public hospitals fled to private hospitals, taking the disease with them. Others were transported to neighbouring regions for treatment, infecting hospitals in new parts of the country. Visiting relatives and infected hospital staff spread the infection still deeper into civilian populations, all across Italy.
The lesson from Lombardy is not a simple tale of “bad” profit incentives, says Sadun, of Harvard Business School. Instead, it was the logical endpoint of a system which had allowed those incentives to distort healthcare priorities over a long period of time. An op-ed in the Italian newspaper Il Fatto Quotidiano described Lombardy’s healthcare system as “concerned only with individual care and profit over prevention”, an approach which “transformed health into a commodity, ignoring prevention because it does not produce profits”.
“The private system has one main goal,” agrees Strada, “and it is not the wellbeing of citizens.”
The approach taken by Lombardy’s equally wealthy neighbour, Veneto, offers a sharp contrast. The region, where private spending only accounts for 7 percent of the healthcare budget and has decreased by 12 percent since 2010, had widespread testing, substantial primary care, and set up dedicated Covid-19 hospitals. Local doctors in antibacterial robes treated sick people in their homes. Although the region was hit hard at first, its mortality rate is now around 6 percent, considerably lower than the 18 per cent rate in Lombardy.
Elsewhere around the world, and especially in the US, the argument that the market can make healthcare more efficient is coming up against the hard fact that preparing for a pandemic involves spending money in the hope that it is not needed. This is something that only the public sector, freed from the motive of profit, can accomplish.
Ben Munster is a freelance journalist based in Italy