Reform of national health service introduces changes in employment relations

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Under a national health service reform approved in June 1999, the role and work of Italian doctors is set to change. "Meritocracy" and training will become the key factors in career advancement, while a single job grade for senior doctors will be introduced, and doctors must choose whether or not to work exclusively in the public sector.

The Italian national health service (Servizio Sanitario Nazionale) was created in 1978. While the Italian welfare system has traditionally been based on an occupational model, in that differentiated services are delivered according to an individual's employment position, since the 1978 reform the health service gas been based on a universal model.

Reform of the health service has long been on the political agenda, and it has become a priority for Italian governments in the 1990s. The goals are both to curb health spending and to improve the efficiency and quality of services. The courses of action which have been identified are: the gradual restriction of the categories of people enjoying free access to health services; the transfer of certain powers from the state to the regional authorities; and the introduction of managerial criteria in the running of the facilities providing health services.

However, the results achieved have not fulfilled expectations. The reform process has been hampered by a number of factors characteristic of public policy formation in Italy, most notably the brief terms of office of the country's governments and the strong pressure exerted by interest groups in defence of the status quo. Moreover, as several commentators have pointed out, the goal of curbing health spending has come to predominate over that of a radical reorganisation of services.

Owing to these partly unsatisfactory results, health service reform is now at the top of the political agenda. The issue has been addressed by the present government, which in June 1999 approved proposals for rationalisation of the national health service submitted by the Health Minister Rosy Bindi.

Implications of the reform for employment relations

The most far-reaching reforms in the proposals approved by the government are those redefining the role of doctors employed by the national health service.

The first change concerns reorganisation of the job rankings of senior doctors. Their division into two levels has been eliminated, and a single "medical management" role has been introduced. Within this single role, functions can be performed with differing degrees of responsibility from both the professional and managerial point of view. The posts with most responsibility will be filled according to merit and capability. Moreover, they will be fixed-term appointments. Every five years, doctors will be assessed in terms of their work performance and results. Those who do not pass the assessment will be transferred to other posts with less responsibility, and will also lose the pay increments awarded with senior positions.

Another important change concerns the exclusiveness of service. In accordance with a provision contained in the 1999 budget law, doctors will have to choose whether or not to work solely in the public sector. Previously, doctors were the only public sector workers who enjoyed the privilege of working full-time in a public hospital while also running their own private medical practices. This system has in some cases provoked distortions in health service delivery due to competition between the public and private sectors. In particular, long waiting lists for public health care induce users to go private, where the same doctors may be working as in the public sector. By autumn 1999, doctors will have to decide whether or not to work solely for the public sector. Only those who take up the option will be given positions of responsibility in public hospitals. Those who instead opt for non-exclusive public employment will have their salaries reduced.

Other points in the reform are: the recognition that the need for constant reskilling requires a significant expansion of continuing training; and a reduction in the pensionable age for doctors to 65 years from the current age limit of 70 (exemptions will only be transitory).


The proposed reform of the health service approved by the government has produced divisions in the doctors' ranks. As is typical in the public sector in Italy, there is a high degree of trade union fragmentation in the health sector due to the presence of autonomous unions, which in the case of doctors are mainly occupational unions. In 1997, unionisation among doctors amounted to about 70%.

The reaction of the trade union confederations and of the main doctors' unions, the most important of which is ANAAO, has been largely positive, despite some internal differences of opinion, though some unions are opposed. The feature deemed most positive is the introduction of "meritocratic" criteria. However concerns have been expressed over the health spending cuts that the government may decide to introduce in the next few months. Moreover, according to ANAAO, the implementation of certain decisions, such as reduced salaries for doctors who do not work exclusively in the public sector, should be postponed until the sectoral collective agreement has been renewed.

Some of the doctors' unions openly opposed to the reform have called a one-day strike and are threatening other forms of industrial action.


As the result of both political choices and self-defensive action by interest groups, the Italian health system has always been markedly bureaucratised. In many cases, this has had a deleterious effect not only on the quality of services but also on the management of the structures responsible for health service delivery. In the field of human resources management, the prevailing model is highly hierarchical.

In the light of this situation, a reform which aims not only to curb spending but also to rationalise the healthcare system inevitably has implications for the role of doctors. They will no longer work solely as professionals in possession of technical expertise, but will also be increasingly called upon to perform managerial functions. This raises new challenges for doctors' professional associations, which in the past have acted mainly in defence of the status quo. It is no coincidence that the government's proposed reform has found most support among young doctors, who feel themselves penalised in terms of career opportunities. It remains to be seen whether a "corporatist" defence of interests will prevail or whether the professional associations will support the innovation. (Marco Trentini, Ires Lombardia)

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