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In December 2003 some newspapers reminded Italians that 25 years have passed since the foundation of the National Health Service, taking the opportunity to present yet another list of critical aspects and shortcomings of the system. Not everyone remembers that the first health law in unified Italy dates back to December 1888, when the National Health System was first introduced. It is with this historical prospective of analysis that it is possible to grasp the characteristics of the present development phase of the Italian health policy, with the possibility to question some institutional and organisational congruencies and inconsistencies that emerge with respect to an economic and cultural context under great transformation.

Progress in scientific research has deepened our knowledge of the entire human life cycle, from birth to death. Survival and evolution are no longer a matter of chance, but the object of planning and, therefore, of choices and decisions. Such a radical switchover has redefined the patterns of socialization process and has provided new interpretation tools for the crisis in cultural affiliation. The ethical debate along with the problem of civil cohabitation can find a link and a perspective only if the centrality of democracy is reaffirmed.

Ours is not an era of global knowledge which undermines and mortifies local knowledge and the participation and involvement of citizens in the government of public goods. On the contrary, the idea of rationality is increasingly been thought of as a sort of patchwork, the result of an operation of «sewing» between local and circumscribed rationality spaces which must be put in reciprocal communication through the availability of a common language and a shared background. It is not by chance that a model of «connective intelligence» is emerging, whose main goal is the identification of distributive or common knowledge and the analysis and translation underway of modalities and courses, through which each of them acquires the capacity to reason about one’s own knowledge and viewpoints, but also those of others. The concept of citizenship must therefore be rethought in the light of these developments.

The heavy burden of health spending on elderly care is common-place in the preoccupations of policy makers and politicians, and is constantly the focus of media attention. The attention on this subject is however rather ambivalent: stress is not placed on the «physiology» of growth in investments for a part of society that «obviously» expresses several needs and is entitled to corresponding rights; the objective complexity of the problem is presented in such a way as to make the solutions appear increasingly more difficult and not due, with the consequent rise in cultural, political and cognitive marginalisation. Analysing four model scenarios, operative solutions, feasible through a participatory way, are indicated at both the local and general levels.

In the paper the author analyses the Italian Health spending in relation to public spending, and proposes a new accountability pact between central government and the regions, aimed at relaunching the National Health Service. Following an historical overview of the foundation of the Nhs and the reforms in the 70s and 90s, the relation between funding and spending from 1999 to 2004 is analysed in the light of documents produced by Institutions and Research Institutes, and compared with other European countries. The paper also presents a detailed analysis of health legislation concerning the regions adherence to the Stability Pact, the agreements signed at the State-Region Conference and the critical financial situations presently registered. Lastly, it examines article 119 of Title V of the Constitution and the new funding system of local authorities which it introduces.

The crisis of the State-nation led to a consolidation of sub-national levels of government. This reinforcement has conditioned recent developments in the welfare state, and particularly in health policy. With reference to the Italian case, the article illustrates the main changes brought into force by the reforms of 1992-93 and of 1999 in terms of the «regionalization» of the health system, and outlines the main steps that led to fiscal federalism, enhancing regional financial autonomy. The closing paragraph takes into consideration possible implications of the process of European integration and, more specifically, the adoption of the Open method of co-ordination on the evolution of the regional health systems.

The paper gives an overview of the historical evolution and characteristics of the s in Germany, the Uk and the Usa. The article also proposes an economic interpretation of differences between the three countries. Germany and the Uk, through different models, assure universal access to health services. In the Usa the residual role of public funding doesn’t manage to make up for shortcoming in the private sector, leaving almost a third of the population without any insurance or with insufficient insurance coverage. High health spending in the Usa, incrementing the diffusion of increasingly expensive new technologies and therapeutic approaches, can put universalistic systems under pressure. To maintain the present structure of European health systems, it is necessary to manage the diffusion of new technologies.

The variations between the notion of essential levels of health care (lea) and the meaning of minimal levels characterised the 90s in Italy and was resolved, in health legislation, with the choice of the Lea and their determination by decree. At the constitutional level, the notion of essential levels of services was confirmed by the constitutional revision in 2001. The paper runs through the steps of this process, the underlying meanings, showing how the notion of essential levels is closely linked to the existence of a national health service, binding together the different regional health services, characterised by their centripetal structure, with the exception of the Region of Lombardia.

The quality of the health services is inserted in a mobile, turbulent context characterised by a long, complex process of corporisation and from the recent, incisive transfer of responsibilities from the central government to the regions, in the health devolution context. However, if we observe the health system transversally, there is evidence of significant transfer of institutional commitment from corporate goals to aims more closely and directly linked to clinical practice and to quality management. Quality, however, has a cost and it is thus also necessary to consider the relation between the research on quality and the cost restriction, a requirement for budget policies of health trusts and local authorities.

Rare diseases are an heterogeneous set of human pathologies whose common features are the low frequency rate in the population (under 5:10,000, according to European criteria) and serious social and health problems associated with such a low frequency. Their number involves a consistent part of the population (approx. 6,000). These pathologies are little known and studied, often chronic and crippling, for which social and health interventions must include support for life and work choices to persons affected. Important public health initiatives are underway at both the national and international levels.

During the 90s, the managed competition model, or quasi-market, was the main reference for the reform of European health systems. The concrete application of this organisational model - aimed at reallocating incentives between financiers, producers and users to guarantee the appropriateness of services, the costs containment and the efficient allocation of resources - has occurred even with numerous variants from the starting proposal and through reforms that followed one another discontinuously, at times emphasising and at other times undermining the pro-competition objectives. In this perspective, the paper proposes an analysis of the reforms experienced over the past few years in England and Italy and investigates the reasons that encouraged these countries to progressively reduce the role of competition, preferring negotiated schemes that were considered to be more compatible with solidarity principles that characterized European public health systems.

Ten years since the promulgation of the decree which introduced one of the most discussed and complex reforms in the last decade, the paper offers an assessment of the effects of the introduction of the system of the prospected payment of hospitals based on the Drg, stimulating a reflection on its efficacy as well as on the possibilities of its successive developments. On the whole, there have been positive results with a significant improvement in the technical-organisational efficiency of hospitals and the containment of the upward trend in hospital spending. However some critical factors have emerged: on the one hand, the persistent delay in the updating of the codification and tariff system, and on the other hand, the potential risks to the quality of services and, in particular, the risk that cost control may supersede the need to guarantee an adequate level of service quality.

The author suggests a reflection on the wide theme of supplementary health insurance schemes, which could help to clarify the real or presumed risks of their diffusion and on the definitions of the most opportune modalities and measures to contrast the risks of diversified access to care services. Considering rather simplistic an analysis which looks at the presence of these schemes as an alternative to the Nhs, the author insists on the centrality of an efficient and effective distribution of essential levels of care. At the same time, he considers opportune and advantageous to overcome hostile positions, that are often the prelude to mechanisms of progressive adaptation that lead to unsatisfactory benefits.

This paper offers a concise overview of evidence from the Isee 2004 Report, which has just been published by the Cabinet and the Employment Department thus providing an updated framework of the provisional data for 2004. A critical evaluation of the Isee can now be given after the first three years in activity as the sole tool wanted by the legislator for the selectivity in social policies. Various problems are here discussed, from the role of immovable and moveable assets to the difficulty in guaranteeing horizontal equity with the Isee given widespread hidden incomes. Particular attention is placed on the matter of the singular criterion for the different services, distinguishing it from the problem of the single information system, a resource to be reinforced and valorised.

The authorised centres for tax assistance (Caaf) run by the trade unions have a crucial role in the presentation and processing of Isee statements (meanstested family income status), indeed the tax centres (Caaf) are now the main partner of Inps (national social security department) for the collection of the single substitutive tax statements (Dsu) and their transmission to the national databank. It thus follows that they provide a fundamental advisory service to the general public. The paper gives an overview of the evolution of their role from 1998 when the new calculation tool was first introduced.

In the Italian language one term «cura» is used to express both the complex therapeutic equipment and procedures used to fight the disease (to cure), as well as the wider and more general attention and concern towards the suffering and fragility of others (to take care of). This polysemy conceals the parallel course of which the two dimensions of care have been the protagonists since the origin of scientific medicine, and which is now making a comeback given the emergence of some phenomena culminating in the incurability of the patient. Yet, to avoid the risk of a sterile reductionism or a mere juxtaposition, it is necessary to go back to the most ancient roots of such an antithesis, going back over the history of medicine from its mythological origins to the beginning of clinical medicine.

The article gives an overview of some aspects of a Formez Research which is still underway, entitled «Emergent courses of integrated social and health planning». The paper examines the first part of the study that considers four regions in the centre-north: Toscana, Lombardia, Veneto, Emilia Romagna. Focus is placed on the analysis of strategies, objectives, courses, actors and tools provided for the realization of social-health integration. The aim is to provide a useful comparative framework of emergent trends from the experiences already conducted and form innovations underway to create shared know-how and common perspectives.

The article analyses the theme of institutional accreditation in Italy, its implementation problems at the regional level in the framework provided in national legislation, and the experience of two regions, Emilia Romagna and Lombardia, which developed different accreditation models. In order to do this, national indications and the role assigned by the norm to the regions on accreditation are considered, together with the delays of the central level and those connected to the process of power devolution to the regions culminating in the modification of Title V of the Constitution. The analysis of some economic, cultural and political problems within the regions, which have influenced the modalities and start-up times of accreditation policies, introduces the accreditation models of Emilia Romagna and Lombardia, that are examined on the basis of different responses given to common critical aspects.