SIMILARLY TO AUSTRALIA, Italy’s focus of public and political debates on strategies to exit from lockdowns has entered a critical phase. Italy, one of the worst-hit countries, is also among the first to have approved an exit plan on 26 April.
It consists of three phases: the first starts between 4 and 18 May, allowing free movement of people only within the region of residence and just for necessary activities such as work and health. Visiting relatives is granted but only with masks and people gatherings are still forbidden.
On 7 May, regions will evaluate contagion rates and for those areas exceeding the threshold imposed by the Ministry of Health, there will be a return to lockdown. On 18 May, the shops will open (second phase) and from 1 June, cafés, restaurants and hairdressers will, too (third phase).
For any exit strategy to be successful, we have to consider, among other factors, the ability of healthcare systems to cope with a latent explosive situation, the effectiveness of the exit strategies adopted by governments and the alignment between the central, state/regional and local governments in implementation. The latter is critical also because it intimately connects to the key of any strategy — people’s behaviour and responsiveness over time. COVID-19 is a global pandemic and without coordinated responses between national and regional levels, we will likely not achieve the desired impact at a community level.
So far, compared to many countries with decentralised or federal (healthcare) systems including Italy, Australia, Germany and Spain, the U.S. has had mixed results, which revealed the limitations rather than the virtues of decentralisation. In Italy and Spain, blame games, particularly directed towards the central administration by the regions reclaiming more flexibility largely for economic reasons, have resulted in a disastrous initial prevention and containment strategy.
As the world knows, this forced a rapid escalation towards the most restrictive lockdown measures ever seen since WWII, even for regions where the epidemic contagion was well below the 1.0 statistically critical contagion rate.
To understand the necessity of a strong alignment at different levels, we should look at three Italian regions with very similar population profiles and with arguably the best healthcare systems: Lombardy, Veneto and Emilia-Romagna. According to the Constitution, each region responded to the emergency autonomously, implementing its own healthcare strategies and policies, which has predictably led to different outcomes.
The death tolls alone provide first insights. As of 28 April, Lombardy reported 13,325 deaths, Emilia-Romagna, 3,386 and Veneto, 1,315. To compare with the rest of Italy, Tuscany reported 778 deceased, Lazio, 389 and Puglia, 399. Nearly half of the country’s death toll is concentrated in Lombardy.
The Italian healthcare system
From 2001, regions gradually gained autonomy and expanded their role and competencies in the management of healthcare services delivery. This process led to a regional drift, with arguably 20 different health systems (one per region) where access to health services is deeply diversified.
Emilia-Romagna put in place a mix of public and private investments, for profit and non-profit, under the stringent direction of the public system. It has produced a system of widespread and highly connected services mainly at a district level. The region has, in fact, been investing resources in territorial and social health through 107 community hospitals (Case della Salute) for 4.46 million inhabitants.
In Veneto, the regional government has invested in the territorial assistance to serve roughly 4.06 million inhabitants with complex forms of primary care aggregation and intermediate hospitalisation structures (community hospitals, territorial rehabilitation units and hospices for terminally ill patients).
Lombardy pursued a model based on competition between the public and the private sector, equalising public and private facilities. The latter has been accredited on the regional system. A study by Sartor on 2017 data shows that 50% of the total number of healthcare facilities in Lombardy are private facilities. The private sector heavily invested in macro polyclinics to gain efficiencies through economies of scale and scope, while extracting rents as strong inpatient care with relatively weak community care has yielded remunerative returns.
Also, in terms of outcomes, the Lombardian system achieved outstanding results in treatments for acute and chronic disease care. However, the system has scarcely invested in adequate coverage of the territory and its communities. Only 27 local health authorities exist serving 10.06 million inhabitants.
Regional differences in COVID-19 responses and outcomes
Looking at the number of tests per 1,000 inhabitants as of 28 April, Veneto has run 71 tests, whilst Lombardy and Emilia-Romagna have run 34 and 33 respectively. Furthermore, Tuscany performed 34 tests per 1,000 inhabitants despite only having a third of Emilia Romagna’s confirmed cases and one-tenth of Lombardy.
Veneto’s COVID-19 policy response was to attack it and can be compared to that of South Korea, Iceland and Singapore — extensive testing of symptomatic and asymptomatic cases, tracing of potential positives starting from the confirmed cases and home diagnosis and care. Lastly, specific efforts to protect healthcare and other essential workers were put in place.
Emilia-Romagna initially started with a defensive strategy. Later, the region introduced drug therapy to treat positive patients at home, preventing their arrival at hospitals in unrecoverable conditions. Moreover, a plan that includes 5,000 swabs per day was launched on 27 March to extend monitoring on risk categories, starting from health and social health workers. Drive-through tests were also introduced to monitor patients at the end of the quarantine.
Lombardy opted for an even more conservative approach, focusing on those with clear symptoms that were accepted in the hospitals. In an interview, Andrea Crisanti argued that the gap in the home testing strategy certified the collapse of the Lombardy healthcare system at a local level. This would also explain why the fatality rate is significantly higher than that of other regions (18% versus the 13% of Emilia-Romagna and 7% in Veneto). Indeed, the number of people infected is much greater, but they are not detected. Most importantly, Lombardy failed to protect its workforce and more than 5,000 health care workers were infected.
Why it is critical to look at regional (or even lower) rather than national statistics
An interesting contribution shows that even if in each regional outbreak the epidemic follows an exponential trend, overall the “sum” of the epidemics can have a different and non-linear evolution. As clear from the graph below, Lombardy’s fatality rate is different with respect to the other regions such as Emilia-Romagna and Veneto. Thus, local data tell a different story compared to the national level.
The differences between regions’ governance and response approaches and outcomes suggest that the impact of the COVID-19 is better explained at a regional level. In light of the current discussions Australia and many countries are entertaining about optimal exit strategies, regional or local flexibility is key. Not only from an epidemiological perspective but also to sustain effective responses and reducing the risk of other waves over time.
The Italian version of this article is available at Quotidiano Sanità, ‘Le Regioni in ordine sparso nella lotta al Covid’, 4 May 2020.
Marcello Antonini is a PhD candidate in Health Economics at the University of Newcastle. Chiara Berardi is an Italian researcher at the University of Newcastle, who is particularly interested in health economic and policy topics. Francesco Paolucci is Professor of Health Economics & Policy at the Faculty of Business & Law, University of Newcastle and the School of Economics & Management, University of Bologna.
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