In the global fight against Covid-19, Italy has so far emerged as the country with the highest death toll. While there are various reasons behind this, the coronavirus has acutely highlighted Italy’s structural and long-term public health crisis. The current shortage of health workers and hospital beds under which the Italian National Health Service (Servizio Sanitario Nazionale, or SSN) faces during this emergency is the outcome of decades of neoliberal economic policies. The number of permanent SSN employees decreased by 5.75 per cent between 2010 and 2018 from 687,000 to 647,000, according to data provided by the State General Accounting Department, while the number of hospital beds available within public structures was slashed by 15.9 per cent from 187,000 to 157,000 during the same period, according to the Italian Ministry of Health.

These neoliberal policies, which have been implemented globally to varying degrees, aim to organise public health according to the logic of the private sector (essentially, profit first) and to weaken public structures to promote private ones. Moreover, this objective was supported by a dominant narrative that depicted public expenditure as ‘wasteful’ and public sector workers as ‘slackers’ in order to reduce resources for essential public services and to discredit the millions of workers who work for us all every day. All of this has prevented any debate on how state intervention in the economy is fundamental, not only to protect the individual health of citizens but also the collective health of a nation. Equal Times recently spoke with Serena Sorrentino, the general secretary of FP-CGIL, Italy’s largest public services workers’ union federation, to discuss the impact and origins of the Covid-19 crisis in Italy.

Since mid-February the SSN has been engaged in a monumental effort to treat the people affected by coronavirus in Italy. Can you give us a sense of the conditions under which SSN staff are working?

The context is characterised by a universal health service that has been weakened by considerable cuts to public funds amounting to €37 billion between 2009 and 2019. Despite being partly reversed in the last budget, these cuts have led to a reduction in staff numbers and a decrease in healthcare facilities, not only for hospital emergency and acute systems but also for local ones, such as primary care, specialised outpatient clinics and nursing homes.

To face the Sars-Cov2 emergency it was necessary to strengthen the intensive care units (ICUs), reorganise the overall health system, create structures fully dedicated to Covid-19 and find health specialists who could work in these places. The lack of personal protective equipment (PPE) and specialists was worsened by the regional management of the national health system. Institutional conflicts between the national government and the regional ones in the first stages of the crisis have made the interventions more complex, as they failed to guarantee the extraordinary measures needed to limit the spread of Covid-19 and to reinforce emergency health services.

During this crisis, the lack of Italian production of PPE has clearly emerged, in particular of face masks, which Italy has had to import at a higher cost or to produce at a national level on modified production lines. What are the effects of this delay on healthcare workers?

This is exactly what I was referring to before. The supply of PPE is a regional competence, but the regional governments acted late, when the phenomenon was already a pandemic and PPE was not sufficient at a global level. The appointment of a commissioner working with the Department of National Civil Protection for such tasks was late. This showed that our previous request to guarantee self-sufficiency in the production of PPE was feasible.

We do not need generic PPE, such as face masks, but equipment suitable for the safety of both the personnel working in structures dedicated to Covid-19 and those working in the essential services sector. These workers cannot be placed in precautionary isolation. The Italian delay on this issue is highlighted by the high levels of contagion of health workers and by the rate of contagion of the population within the outbreak areas.

In the midst of this emergency, Italy was forced to call back retired doctors and borrow healthcare staff from other countries. At the same time, around 1,500 young, specialist doctors emigrate from Italy every year. What’s behind this contradiction?

Years and years of wrong policies such as freezing the hiring process in the health system and the whole public sector in general; the limited enrolment in the faculty of medicine and in specialisation schools; poor appreciation of professionals; and finally, low wages. The health workers that are educated in Italy start their relationship with the SSN through precarious jobs and with a lack of recognition of their professional skills. These high-level workers go abroad to find a scientific and organisational environment that is more receptive to investing in health professionals.

Italy has one of the best health services in the world. However, over the past few decades the SSN has undergone funding cuts, which many national governments have justified with the need to keep budgets balanced. What are the results of these policies?

A strong inequality in terms of distribution of services. The public sector shrank due to cuts in health staff, hospital beds, home care networks, primary and intermediate care, and a total lack of chronic conditions management. This led to an increase in the market of private accredited health services, causing – paradoxically – an increase in overall spending. Hence, the expenditure for the enhancement of public health structures has decreased, while the purchase of private health services has been increased. We do not need to rethink the values of the SSN but implement them, revising the roles of the national and regional governments, and linking health expenditure to the needs of the population.

Therefore, the risk is that the right to health, enshrined in the Italian constitution, depends more and more on an economic agenda that is profit-led. What is the labour situation of private health workers? And what role are private health facilities playing in this current emergency?

As in all cases of outsourcing, private health workers are suffering from a reduction in wages and rights due to the need of the private sector to guarantee its own profits. These workers have been waiting for the update of their national collective bargaining agreement for over 13 years. The private health employers have interrupted the talks on the most important issues, which is that private and public workers should have the same wages and rights.

In this emergency, private health employers have ‘seized’ the opportunity to gain more. In some regions, they have made ICUs, structures and professionals available, but in others, they are maintaining all those medical activities that could be postponed, increasing the risk for patients and health workers. Moreover, they are only available to help in the emergency [in areas] where the profit margin is high, without recognising the value of the professionals. Not everyone has behaved like this but the private sector in Italy is not setting a good example. It is not always considering this pandemic emergency as a priority in which all structures have to contribute, even with sacrifices. I think that nursing homes for the elderly are becoming a symbol of the lack of employers’ social responsibility. They have left their employees without PPE and have not considered the vulnerability of the elderly, which are the main victims of the virus.

This health crisis has reminded us of the fundamental importance of the principles of universality, equality and solidarity that have inspired the SSN since its foundation in 1978. After decades of continuous cuts, how will it be possible to revamp the SSN in the aftermath of the Covid-19 crisis?

We need a mobilisation of skills to reshape the map of the health services. The principles are still valid, however there is a lack of resources and personnel in two strategic areas: prevention and research. The initial phase will have to be characterised by investment. When prevention, primary care, nursing homes for the elderly and the chronic care network all work properly, health expenditure is reduced and the quality of services is higher.

In addition to the health sector, the Covid-19 emergency has also impacted other parts of the public sector: from environmental hygiene to prison officers, firefighters and local police. How fundamental is their contribution?

The management of this emergency involves many areas of public services. It is necessary to guarantee public safety, environmental and territorial protection, the administrative services related to public administration, the civil protection system, and all those activities that cannot be suspended. It is still necessary to guard inmates, collect and dispose of waste, guarantee urban safety, provide social protection and welfare services, and take care of people. The same workers that for years have been attacked by policies aimed at making the public sector ‘more efficient’ are now on the frontline in the fight against Covid-19.

Today, nurses, doctors, local and national police officers, firefighters, prison officers, sanitation operators, social workers, educators, cemetery services’ workers and workers at social security institutions are all doing their jobs without adequate PPE, which exposes them and their families to the contagion. These workers, and all essential workers, are guaranteeing the services needed by all citizens. They do this out of a sense of duty and commitment to the public. There is a need to rethink the role of public services not only at a social level but also at an economic one, overturning the paradigm that considers them as an ‘expenditure’. We also need to understand that there is no development without well-being.

The Italian national government has undertaken several measures to deal with the coronavirus emergency, including the so-called ‘Cure Italy’ decree. What is your assessment of this and what requests has the FP-CGIL made to the government?

The list is long. Starting from the evaluation, the decree is a first act to support what we have to safeguard today: the SSN, household incomes, and the production structure of public administrations, services and goods providers. Other European countries, perhaps because the emergency came later, are preparing stronger medium-long term policies. This could expose Italy to a slower and more uncertain economic recovery, which is why it is so important that the Italian government is already working on new measures.

Regarding this, I noticed that there are still many unanswered questions in our sector, in particular on hiring and organisational issues in the health system. The SSN is currently under stress and this is the priority: new staff must be hired, and health workers must work safely and be paid adequately.

There are many sectors exposed [to the dangers of Covid-19], from the social private sector to environmental services, and in general all those who work with public clients. The biggest problem will be to secure the budgets of administrations, investee companies and contracted activities. Today we are tackling the problem of income support but in a short time we have to think about a long-term transition. The loosening of the fiscal restrictions is an opportunity to be seized with a strategy to reshape and keep production activities in Italy, and consolidate public services.

The FP-CGIL has launched the ‘Thanks to those who work’ campaign [‘Grazie a chi lavora’ in Italian] to highlight the importance of essential public services and the workers who work every day for all of us. Once this emergency is over, how do we start to fix our public services?

By rebuilding the trust of workers, which for us means decent wages and professional enhancement. By preparing an extraordinary hiring plan, by giving a central role to the programming of services, by understanding community needs, and by redefining the operational area of universal public services.