Italian territory and governance of the healthcare system from the central government to the regions

The Italian territory is divided in 20 regions. Those public entities are autonomous from the geographical, political, and administrative point of views. Each region is divided in different provinces. Each province is divided in different municipalities. From the urban governance perspective, in the table below is enlightened how many provinces and municipality have the different regions and how many large or medium urban systems exist in each region.

Table 1 – Overview of the Italian regions and Covid19 cases

In red the regions which have been more hit by the Covid-19 pandemic with the total amount of cases. The sum of known people tested positive to the Covid19 virus in the sixteen not-red-regions (see the table) corresponds to 75% of the total cases in Lombardia. The latter had three times more cases than the second most hit region: Piemonte.

The Italian healthcare system (or SSN – Sistema Sanitario Nazionale) is defined by the National Law n. 833 instituted in 1978, accordingly to the article n. 32 of the Italian Constitution. The latter is based on three pillars: universality, equality, and equity. From the governance perspective, the central government determines what are the LEA (or Essential Levels of Assistance) which must be guaranteed at the national level. The regions, on the other hand, have the responsibility on the actual administration and management of the funds (77% of the spending are public). The Ministry of Health (central authority) is in charge of the SSN. [3]

Before 1978 the healthcare system was managed by the USL (or Local Healthcare Unit), which were public entities under the control of the different municipality. After that year, the SSN was established, and the organization passed from the municipality (local) to the regions. The idea was to make the healthcare system more homogeneous on the national territory.

Any healthcare-related issue, policy, and solution is addressed by the central government (Prime Minister and the Ministry of Health). The LEA are decided by the national government. Before 1978, the different municipalities (closer authority to the citizens) administrated and managed the healthcare system on the local level. After 1978, the healthcare operators became the regions with more private investments. This decision did not make the Italian territory more homogenous from the healthcare point of view; instead, created less, bigger (geographically and financially) authorities not connected to each other.

Exchange of information, strict cooperation, public professional partnership between the regional authorities can be some of the answers to a more homogeneous healthcare system in the Italian territory. Coordination between regions, at the moment, is desirable, but generally not adequate.

Covid19 in Italy: numbers and the Pandemic Protocol

Table 2 – Overview of Covid19 cases, testing, and ICU per region

The region with the highest percentage of cases in respect to the swab tests implemented is Lombardia. Followed by Piemonte, Liguria, and Emilia-Romagna. As discussed later in this paper, Veneto has been an uncommon case: despite the high number of cases, the percentage in respect to the swab tests is one of the lowest of the country. Veneto carried out almost as many tests as Lombardia, but the cases were from 4 to 5 times lower.

ICUs (Intensive Care Units), as known, are the most critical issue for the different healthcare systems in the different cities. Several regions managed to double (or more) the ICU beds within few weeks after the breakdown. In order: Piemonte, Trentino – Alto Adige, and Liguria.

According to the website of the Ministry of Health, after the A/H5N1 virus (Bird Flu), the WHO asked to the world’s countries to study and develop some plans in case of pandemic. Italy already adopted the first Piano Pandemico Nazionale (or National Pandemic Plan) in 2002. In 2005 there was an update with the objectives and goals of the WHO documents. The last version of the Italian Pandemic Plan is dated December 2016 [6]. At the end of the document it is asked to the different regions to develop their own Regional Pandemic Plans following the national guidelines [7]. The most important objectives are: identify and confirm as fast as possible the first cases; minimize the risk of transmission; reduce the impact of the pandemic on the social and healthcare services; ensure an adequate training of the healthcare workers; guarantee fast and updated information for the public and the healthcare workers; monitor the efficiency of the previous actions [8].

Chronicle of Covid19 in Italy: dates, laws, and responses

On the 30th of January were confirmed the first two cases of Covid19 (two Chinese tourists hospitalized in Rome). The same day the central government stopped all the flights from and to China. On the 31st of January the Italian government declared the State of Emergency; it nominated commissioner of the emergency Angelo Borrelli (Head of the Protezione Civile) and it instituted the technical-scientific committee in order to manage the emergency.

The first secondary transmission case (first Italian pandemic outbreak) was in Codogno (Lombardia region) on the 18th of February 2020 [9]. WHO announced the Covid19 outbreak as a pandemic on the 11th of March.

Following all the laws concerning the Covid19 crisis and the timeline:

  • First Decree passed on the 23rd of February 2020 by the central government. It contained the first measures in order to forbid to get in and out of the municipalities affected by the pandemic outbreak (10 little villages in Lombardia region – Codogno, Castiglione d’Adda, Casalpusterlengo, Fombio, Maleo, Somaglia, Bertonico, Terranova dei Passerini, Castelgerundo e San Fiorano – and one little town in Veneto region – Vo’ Euganeo). In this decree has been suspended all the events and manifestations in the national territory [10].
  • After this first central governmental act, on the 11th of March 2020 all the not first necessity commercial activities are forced to close. The new law has been called #iorestoacasa (I stay home) [11].
  • On the 22nd of March the central government forbid to any private citizen to move outside of its municipality except that essential work or healthcare reasons. All the productive activities not essential or not strategic are closed. Only grocery stores, pharmacies, and tobacco shops stay open. All those measures stay active till the 3rd of April 2020 [12, 13].
  • On the 1st of April 2020 all the measures described in the previous laws remain valid till the 13th of April 2020. All the sports training stop, of any kind [14].
  • On the 10th of April 2020 is decided that the lockdown period continues till the 3rd of May 2020, except that newborn stores, bookshops, and stationeries [15].
  • On the 26th of April 2020, it is identified all the “Phase II” measures starting from the 4th of May 2020 (42 days after the lockdown period started). Most of the commercial and productive activities can open again except for restaurants, bar, etc.… Any event or manifestation is still forbidden [16].
  • The last Legislative Decree was published on the 17th of May 2020. From the 18th of May 2020 any commercial, productive activities can start open again following two rules: social distancing and mask (especially in closed spaces). People can go out of their own municipality, provinces, and regions. All those measures are valid till the 31st of July 2020 [17].

On the 11th of June 2020 is officially started the Phase II with the Governmental Decree [18] which allows from the 15th of June most of the activities and movements. Regional governments still have a say on the majority of the activities (theatres, cinema, spas, cultural centres, etc…) depending on the territorial pandemic curve. All sports can start again but without audience.

Governance of the crisis and coordination between the authorities (national, regional, and local level)

The central government issued the legislative decrees listed above transferring to the regional level the decisions on how to face the crisis from the healthcare point of view. Regional government had to manage hospitals, healthcare workers, retirement homes (RSA or Residenze Sanitarie Assistenziali), ASL (Aziende Sanitarie Locali or Local Healthcare Units). The big urban centres, as well as all the municipalities, did not have a lot to say on the crisis period. They could help the central and regional governments to let citizens respect the rules.

Regions collaborated at some level: most of the south Italians hospitals welcomed several patients in theirs ICUs in order to unburden the stressed north Italian healthcare systems. On the other hand, most of the regions were left alone in the production of health security devices; in some cases security goods came faster and in bigger amounts from foreign countries (in Lazio from the Chinese government, in Piemonte from Cuba, in Puglia from Turkey…), than from the regions nearby.

Coordination between central and local governments was central from the security point of view. Most of the police forces are under the authority of national powers (Ministry of Defense, Ministry of Interior, Ministry of Economy and Finance…), except the Municipal Police (under the control of the local administrators). The coordination between Municipal Police and the National Police Forces has been crucial in order to monitor the Covid19 national measures and – eventually – fine the offenders. More than 14 million people have been stopped and checked. Almost 400.000 citizens have been sanctioned because they were not respecting the rules defined in the Legislative Decree. Data from the 28th of march to the 14th of June 2020 [19].

Local authorities had the hard responsibility to decode, understand, and communicate to the citizens the laws of the central and regional governments. It occurred, more than once, that the several Legislative Decrees were not clear in one or more articles. City’s mayors were and are the last knot in the infinite Italian bureaucracy-net and governance-net. Citizens trust the closer political and social authority. An the latter is fundamental also in the back-to-normal process because they can change the “small” urban environment, transforming the crisis in an opportunity.

Veneto and Lombardia: two different reactions to the Covid19 crisis

The northern regions of Italy were the territories with the most cases. In order to understand what regions could do or did, two cases will be analysed. Lombardia region is described as worst-case governance of the crisis; on the other hand, Veneto region – according to the virologists – managed the crisis better than any other region in Italy, although still really hit by the pandemic.

Lombardia region 

  1. The Regional Council Decision (with precise indication on the management of the pandemic in the territory) was signed on the 23rd of March 2020 (more than one month after the pandemic outbreak in the region). For one entire month family doctors and healthcare workers had no instructions about what to do exactly.
  2. Before the crisis, the ICU were undersized in respect to other regions (e.g. Emilia-Romagna or Veneto regions). 8,5 ICU per 100.000 inhabitants in respect to 10.
  3. The retirement houses were closed to the family’s visits on the 4th of march (10 days after the pandemic outbreak in the region). Plus, from the 8th of March all the patients with mild symptoms were un-hospitalized and were taken to the RSA. 53,4% [20] of the people that died (3045 at 17th of April 2020) in the RSAs from February in Lombardia region, had Covid19 symptoms. In respect to 2019 the total deaths were 2666 more (+270%) [21].
  4. Instead of investing in more swab tests than what the central government advised (the minimum amount, only for the polysymptomatic patients); the region spent between 17,3 and 21,6 million € [22] for a new hospital at Fiera di Milano (north-east of Milan). It is not clear the amount of money which have been public and how much were private donations. The hospital was built to offer 600 beds, but after 16 days from the inauguration (31st of March) there were only 10 patients hospitalized [23].
  5. One of the hospitals (at the start of the pandemic) with the highest number of Covid19 patients was the one in Alzano Lombardo (Bergamo, Lombardia region). That area wasn’t closed immediately, and the hospital was reopened instead of closing it off to normal patients. It is not clear what authority decided (region and central government are still debating).

Veneto region

 The hospital in Schiavonia (Padova, Veneto region), where the first Covid19 death occurred, was closed off the night before the central government signed the first Legislative Decree that identified the red zones.

  1. The region, after the WHO publicized the first protocols about the swab tests on the 20th of January 2020, bought reagents in order to analyze 500.000 swab tests [24]. In a second phase most of the reagents were self-produced by the region.
  2. At the end of March 2020, Veneto region bought an American machinery which allowed the laboratories to analyze more than 9.000 swab tests per day. Veneto region has done almost as many tests as Lombardia region, but the positive cases are 5 times lower. In some cases (the population of Vo’ Euganeo – red zone), all the inhabitants were tested by regional deliberation.
  3. The shape of the Veneto’s territory is less urbanized than Lombardia region (the most hit area in the Lombardia region – Val Seriana, Bergamo – is characterized by a lot of little towns interchanged with huge industrial zones).
  4. At the contrary of Lombardia region, Veneto region decided to hospitalize only the patients with real medical needs. In Veneto only 15% of the total Covid19 positive people were in hospitals, in Lombardia averagely they were 40% [24]. The general rule for people with mild symptoms was to stay home.
  5. All the doctors and healthcare workers (especially in the hospitals) already on the 23rd of February were trained and protected with the needed safety devices. Every 10 days all of them were and are tested [24].

Covid19 and the mobility sector: what happened

Since movements were forbidden, the mobility sector has been characterized by a massive crisis:

  • car registration decreased by 85% [25],
  • fast train travels between big cities cut almost completely (98% less trains) [25],
  • from 60% to 70% less usage of Car Sharing in the medium/big urban centres [25],
  • car rental fell by 98% (short-term) and by 80% (long-term) [25].

Private and public companies were hardly hit by the economic loss. Nowadays the users prefer a more secure transportation mode (cleaner, safer, not crowded…) rather than a cheaper or a more sustainable one. Sometimes security, cheapness, and sustainability can coincide.

North of Italy was the centre of the pandemic. From the left to the right, it is shown how the urban mobility and the transportation between main urban northern centres changed. At the end of March – averagely – the mobility was between 10% and 15% of the baseline (traffic in January).

 Figure 1 – Remaining mobility in the weeks 15/02-21/02, 21/03-27/03 and 23/05-29/05 as percentage of January traffic [26]

Figure 2 – Different mobility modes in Milan (top-left), Rome (top-right), Naples (bottom-left) from 13th of January to 20th of June [27]

Driving, walking, and transit traffic changed drastically. In Milan, between the end of March and the first week of April, data report minus 95% of mobility. Rome and Naples reached almost the same levels. At 20th of June, if in Naples the mobility is at the same level of the January baseline; in Rome and in Milan driving is still slightly less common than what used to be in January, but walking and transit are still 40% / 50% less than January.

Covid19 and the mobility sector: what will happen from now on

The so-called Soft Modes (bicycles, walking, electric scooters…) can become as used as the cars, especially in medium-big urban contexts. Large urban systems can still invest in those kinds of transportations, but it is less likely that they become the most used.

Big cities, on the other hand, will have at least three different challenges to overcome in the next months or years:

  • Higher costs for the public transportation systems declined in:
  • More routes because of the social distancing. Public and/or private operators need to organize more buses, trams, trains… having available the same amount (or probably less) of users and revenue consequently.
  • Digitalized line management so that social distancing is respected, and users do not have to wait a substantial amount of time which will cause a reduction of the utilization.
  • Continuous disinfection of the vehicles, and/or public designated position with alcohol-based sanitizers in order to allow users to have clean hands before getting in buses, trams, trains…
  • Complete renovation of the urban transportation infrastructures with a special consideration for the Soft Modes. In most of the big Italian cities the municipality is investing in bicycle lane, pedestrian path, residential small roads at 10 km/h or 30 km/h, scholastic roads.
  • In Rome has been discussed the Mobility Plan with 3,8 M€ per 150 km of bicycle path [28].
  • In Milan, the city hall is developing 35 km of bicycle path to add to the existing 200 km, enlarging the walking path, developing urban service roads at 30 km/h, improving the signage [29].
  • In Naples, the Mayor announced more bicycle paths and walking paths, and he said that they are working on a feasible plan for the city [30]
  • In Bologna, the city in working on the development of the “Bicipolitana”. Within few weeks all the work sites will open again. The goal is to realize 60% of the 493 km of the green-mobility infrastructure within the 2020. 145 km exists already, and they are articulated in 6 main directions plus 6 complementary paths [31]
  • In Torino, the municipal government is betting on the slow-driving urban service roads. Private car’s drivers will use these secondary roads only to turn on other streets, and to park. The speed limit will become 20 km/h and these paths will be used especially by bicycles, scooters, and pedestrians. At the moment Torino has 190 km of bicycle paths, but in the near future the city is investing in 120 km more. Torino is characterized also by the highest number of car sharing, bike sharing, electrical scooters sharing companies [32]
  • In Genova, instead of investing in bicycle paths, due to space reasons, the city decided to invest in “bike lanes”. The latter are small portions of normal streets which will be used only by bikes, deducting space from the car’s lanes [33]
  • Reinforce the PPPs with more collaboration in order to enhance a complete data sharing for a coordination and monitoring of the citizens movements, being careful with the privacy of any users [34].

The Covid19 crisis will have (and it is having) an important impact on the mobility sector. Evidently, technology and society in the urban context, and not just that, are two of more interesting dimensions to discuss.

  • From the technological point of view, digitalization and economic crisis are the key words. They are two conflicting factors which will have to merge in some way. If the digitalization could bring new techs in the mobility sector (autonomous vehicles, electrical cars, 5G connected vehicles or public transportations, etc…), on the other hand the economic crisis of the mobility sector will reduce the investments in this directions.
  • From the social point of view, the key words could be the same but declined in a different way. In this dimension, digitalization and economic crisis move together. Users won’t have liquidity to invest in traditional mobility (cars, yearly public transportation tickets, etc…), as a consequence the solution will be new, cheaper, non-traditional transportation modes (car sharing, scooter sharing, bicycles, etc…).

According to a Deloitte report, 70% of the interviewed people know what car sharing is, but only the 7% of them use it normally. Same think with the bike sharing, 65% know what it is, but only 7% use it regularly [35]. Those percentages tell us that people are aware of new mobilities, but they did not have the chance to try it for different reasons (hard to access for some of the users e.g. elderly, laziness, convenience).

The Italian government, following those directions, gave to all the citizen living in big/medium cities (more than 50.000 inhabitants) who asked for, a 500€ voucher to buy bicycles, electrical bicycles, or electrical scooters. The consequence has been more than 200.000 bicycles sold in May 2020 (+60% in respect to May 2019) [36].

The environmental challenge in large urban systems is strictly connected to the mobility. Covid19 crisis, despite everything horrible it created, could represent for the regulators an opportunity to improve the transportation modes in the cities: soft modes, electrical sharing vehicles, bicycles are just some of the responses of the different local government in Italy which can be (or are) replicated by all the cities in Europe and in the world.






































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