The following text is a summary of the article published in the Theme section of no. 2/2018 of the Journal of Social Policies. This is instead the links to the column that Rassegna dedicates to the publication.

The year 1978, so full of significant dates for health on a national level (law 833/78, law 180/78, law 194/78) and international (Declaration of Alma Ata, September 1978), represents a sort of watershed in history (also in the field of health care), with a "before" and a "After". The "before" is the period following the end of the Second World War, in which the expansion of universalistic welfare is recorded - a common trait of European liberal-democratic and social-democratic governments - and the principle is affirmed according to which some fundamental services, such as education and healthcare, must be removed from market mechanisms and therefore be guaranteed by the State, to offer equal opportunities to all and to reduce the risk of widening inequalities within society (caused precisely from the market).

The "after" starts in the early eighties, with the election of some ultra-conservative leaders – Margaret Thatcher in Great Britain (1979) and Ronald Reagan in the United States (1980) – and with the emergence of neoliberalism. Neoliberal policies also apply to healthcare, which is becoming a land of conquest of the market on a global level, as stated in an article by The Lancet of 2001: “Over the past two decades, the drive towards market-based health system reforms has spread throughout the world, from North to South, from West to East. The global model of health system has been supported by the World Bank to promote the privatization of services and increase private financing through direct payment of services (user fees). These attempts to undermine public services, on the one hand, pose a clear threat to equity in countries with robust welfare systems in Europe and Canada, on the other, they pose an imminent danger to the fragile systems of countries with medium and low income".

Rudolf Klein has compared the transformations of health systems that have taken place since the 1980s onwards in every part of the world, to a sort of planetary epidemic. A powerful motivation for the restructuring of health systems is to be found in the need to face the costs deriving from growing consumption fueled by the extension of the right to access services, the aging of the population and the introduction of new biotechnologies. In the period between 1960 and 1990 in the 29 most industrialized countries belonging to the OECD, the median health expenditure per capita had increased from 66 to 1,286 dollars, while the median percentage of health expenditure on GDP rose in the same period from 3.8 to 7.2%.

The need to contain costs by eliminating inappropriate or unnecessary expenses and giving the system more efficiency, it was accompanied by another type of push, of a political-ideological order: the tendency towards privatization and the introduction of the free market, according to the lines of neoliberal politics. The chronological coincidence of the two types of pressure ("more efficiency" and "more market") had the effect of giving more strength and justification to the second, through the following reasoning: only by applying the rules of the market, i.e. by injecting powerful doses of competition and privatization, the system can become efficient.

In 2011 the English magazine BMJ extension published an article signed by two of the most well-known and expert analysts of international politics, Martin McKee and David Stuckler, entitled "The assault on universalism”. According to the authors, the reform of the National health service (NHS), then in gestation, wanted by the conservative government, aimed to dismantle the glorious National Health Service, born in 1948, from its foundations: it was a real assault on universalism. Their thesis was that the economic and financial crisis was being used to destroy universal welfare systems, such as the NHS and other national health services: “The economic crisis has offered the government a once in a lifetime opportunity. As Naomi Klein has described in many different situations, those who oppose the welfare state they never waste a good crisis.”

In the UK, the feared NHS reform came into force in 2013, producing the total privatization of health services. A similar fate befell Spain: here too a conservative government did not miss the opportunity provided by the crisis to get rid of the universal healthcare system – with a simple royal decree (April 2012) – to hand everything over to the insurance companies. The assault on universalism is also underway in Italy. But unlike what happened in Great Britain and Spain, in our country the assault has not found a transparent political and legislative path.

In Italy the assault on universalism - and on the founding principles of law 833 approved 40 years ago – manifests itself in a design bipartisan based on the definancing of the public health sector and the promotion of the private insurance "second pillar". A design very similar to the one hatched in 1992 by Minister De Lorenzo, but made much more dangerous today by the convergence of multiple interests and the absence of any resistance on the "left". It is to be hoped that the many initiatives that are in the pipeline to commemorate the 40 years of life of the National Health Service will serve to awaken from their sleep the political and trade union forces that have (or should have) the concept of right in their ideal baggage to the health and equality of all people in the face of disease.

Gavino Maciocco is professor of public health at the University of Florence

rassegna.it – 12 dicembre 2018

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Law 23 December 1978, n. 833 “Istituzione del Servizio Sanitario Nazionale.

• 29. La produzione e la distribuzione dei farmaci devono essere regolate secondo criteri coerenti con gli obiettivi del servizio sanitario nazionale, con la funzione sociale del farmaco e con la prevalente finalita’ pubblica della produzione.
• Con legge dello Stato sono dettate norme: … g) per la regolamentazione del servizio di informazione scientifica sui farmaci e dell’attività degli informatori scientifici
• 31. (Pubblicità ed informazione scientifica sui farmaci). – The National Health Service is responsible for providing scientific information on medicines e di controllo sull’attività di informazione scientifica delle imprese titolari delle autorizzazioni alla immissione in commercio di farmaci. …
• Nell’ambito del programma di cui al precedente comma, local health units and businesses referred to in the first paragraph, in compliance with their own competences, they carry out scientific information under the control of the Ministry of Health.
• Sino all’entrata in vigore della nuova disciplina generale dei farmaci di cui all’articolo 29, il Ministro della sanita’ determina con proprio decreto i limiti e le modalita’ per la propaganda e la pubblicita’ presso il pubblico dei farmaci diversi da quelli indicati nel precedente comma, tenuto conto degli obiettivi di educazione sanitaria di cui al comma successivo e delle direttive in materia della Comunita’ economica europea.
• Ministerial Decree of 23 June 1981 – Art. 1- ripreso dal Ministerial Decree November 23, 1982 And Ministerial Decree February 26, 1985.
• ” L’ attività di informazione scientifica sui farmaci ad uso umano …. deve essere volta ad assicurare il corretto impiego dei farmaci stessi, anche with reference to the need to limit the related consumption".
• … Considerati i riflessi dell’attività dell’informatore medesimo nell’ambito del Servizio sanitario nazionale, è da ritenere qualificante l’instaurazione di un rapporto di lavoro a tempo pieno e subordinato.