The rise and fall of democratic universalism: Health care reform in Italy, 1978-1994

In 1978, a sweeping reform created the first national health service of continental Europe: Italy's Servizio Sanitario Nazionale. This new scheme was based on the principle of 'full democratic universalism': The state would provide free and equal benefits to every citizen and the organization of public health would be subject to popular control, essentially through political parties. However, the severe problems encountered in implementing the reform design and rapidly increasing health expenditures soon eroded any consensus on this principle. Thus the 1980s and early 1990s witnessed a gradual shift to 'conditional and well managed universalism.' These latter principles stress the need to differentiate access to care according to some criterion to regulate demand and the need for efficient use of scarce resources through adequate valorization of managerial skills and the use of 'market-type' incentives. An elaborated system of user copayments was introduced gradually, and in 1992 a 'reform of the reform' profoundly changed the organizational framework of the Servizio Sanitario Nazionale. The new government elected in the spring of 1994 announced ambitious plans to partially dismantle public universal insurance. Although these plans may prove difficult, the potential to form an anti-universalistic coalition seems strong in the contemporary Italian health care arena.