Prof. Walter Ricciardi has just been appointed as the new president for the Italian National Institute of Health (ISS). He explains his priorities since taking office, the crucial role the ISS plays in the NHS and his vision for the future of the Italian National Healthcare System.
Prof. Ricciardi, can you explain the role the ISS plays in Italy’s National Healthcare System, and what your priorities have been since taking office?
I took office as president on September 1st, but have spent the last year as a government commissioner to the institute. If the working title of your report is ‘A Tradition of Resilience’ then this organization is indeed a good example of that resilience. When the government asked for a commissioner to be appointed, their reasons were problems in the funding and management of the institute.
Today we have reinvented the ISS based around its areas of excellence. We have 2500 people working for the ISS, of which only 200 are administrative staff with the rest being comprised of researchers and technicians. This makes the ISS instrumental to the Italian NHS and in keeping our health system in its current form; funded by taxpayers, with universal coverage of the population and with citizenship bestowing entitlement to healthcare. In order to retain that, we need to create a new governance model, beginning with a change to our constitution. In 2001 the constitution was modified, with the healthcare system pioneering this change. Essentially the provision of care was delegated to the country’s 19 regions and two autonomous provinces, and this was a problem. The state kept only essential competencies, but not sufficient to grant a homogeneous, effective and efficient system in the country. So we spread heterogeneity rather than homogeneity, the results of which is two-sided. First, we have today the most efficient healthcare system of any large country in the world (the first overall being Singapore, with Italy second). If you look at the indicators, this is caused by Italy’s incredibly good scores on health indicators such as mean quality of life and life expectancy, with relatively low spending on healthcare. Our problem however is the second effect, which is the heterogeneity among the regions. Some regions will have world-class care, with very efficient systems, while others have a poor standard of care.
The changes required to address this are being discussed in parliament now, they are approving a change in the constitution on which we will have a referendum later this year. The hope is that this will bring the exclusive responsibility for health back to the state, which does not imply that the regions do not need to play a role, but it does give us the power to impose certain standards. This is where the importance of the ISS, AIFA and Agenas come in, because of course no national health service can work without technical, scientific agencies supporting decision-makers with the information they need. Like this we can estimate the triple values which we believe any future health care product will need to fulfill. These values are, first, the personal value to the consumer, second, the value for the professionals providing the services, while third is the allocative value. We as the ISS are going to be instrumental in evaluating this value in collaboration with AIFA, Agenas and the Ministry of Health. This is our priority. Making this system work will give our stakeholders; the regions and the citizens, the best provision of health services possible.
As you said, making intelligent healthcare decisions requires the necessary data. With the regions being very heterogeneous in their provision of care, what tools does the institute have in place to gather reliable data throughout the country?
We already have plenty of data, but our system is severely underestimated, undervalued and underused. The problem that we have is that it doesn’t provide enough information. This is because the data we provide is being used in silos, so the Ministry of Finance is using our financial data, while the Ministry of Health is using the data on healthcare indicators. This needs to change, we need to start breaking down these silos in order to gain new insights on the state of the healthcare system, and so provide decision-makers with the appropriate tools to decide. This is something we are working on, to give you an example, even within this institute data was scattered and underutilized. Now another priority is to consolidate this data and distribute it in usable form to the stakeholders. So there will be a transparent and open platform for people to gain access to that data easily. On top of that of course we want to provide useful information, but usable data is the first step.
Italy is renowned for the excellence of its scientists, and they are undoubtedly one of the country’s most attractive features for international companies looking to invest here. Recently you talked about Public Private Partnerships (PPPs) as crucial for the country, how can the ISS encourage these?
Italy is a country in which we certainly have some prerequisites for effective PPPs, but not all of them. We have had difficulties in the past in creating the right eco-system for attracting investment, and one of the issues standing in the way of that is our bureaucracy. We are aware that our bureaucracy is one of the worst. It has played some role for good, as many countries have not been able to keep their budgets under control, while Italy has, so that certainly has been a great success for our Minister of Finance. However, budget control alone is not enough. We want to create an environment in which investors can come and be certain that their investments will be evaluated in a timely and sensible manner. In the case of ethical committees for example it is clear that the heterogeneous system we had in place was detrimental, with decision-making processes and results being very different among the regions, so we are fully aware that this needs to change, and the ISS is supporting a move in that direction.
Where do you see opportunities for collaboration with the industry?
First of all, we have excellent clinical centers, and it is a big asset for private investors. There are certainly other countries hosting less expensive trials, however it can be worth it to invest a bit more, in order to be certain of the quality you get in return. In Italy we can offer that certainty.
We also have a structure which directly links scientific research to practice. This is comprised of a network of approximately thirty scientific institutes operating directly under the Ministry of Health, which are able to immediately link the results of research to practice, in order to shorten the gap between scientific research and implementation in practice.
Finally, we also have the possibility of creating a number of highly effective scientific parks. Currently there are too many of these facilities, and they are too scattered, so we want to reduce this number to make them more efficient and effective. There is a discussion in Italy about repurposing the area used for Expo 2015 and investing in it as a scientific park, where biomedicines and scientific research will play an important role. We are thinking of concentrating 1600 researchers there, so that is another example of concentrating a large number of smaller centers into one which is far larger and more effective as an investment.
The common message I am hearing is about consolidation. Whereas Italy has a very spread-out system right now in terms of data, of ethical committees and scientific efforts, what is needed now is to consolidate, is that the future for Italy?
Yes, consolidation, coordination, data- and knowledge-sharing and speeding up the processes for decision-making, those are the key words for our country’s healthcare system moving forward.
A final question, what are your personal ambitions for your role as President of the ISS?
I am an academic, I have been working in research for many years, and was actually a professor of public health at the Catholic University of Rome. Besides that, I have held many roles internationally, formerly serving as the president of the European Public Health Association, I have been the first non-English editor of the Oxford Handbook of Public Health and the first non-American member of the National Board of Medical Examiners in the United States, so I was one of the people hesitating to stay in Italy. When the Ministers of Health and Finance called to ask me to take this post, I agreed because I strongly believe that Italy is a country which has the conditions for creating an excellent environment for scientific and business excellence.
So my personal ambitions are to spend the next four years of my mandate working for my country, working for the citizens, the professionals, the industry, and the other stakeholders, and I am fully optimistic that this can happen.
In the European Parliament you can find a postcard, humorous of course, on the stereotypical idea of a European heaven and a European hell. The European heaven would be where the police are British, the lovers are French, the mechanics are Germans, the chefs are Italian and everything is organized by the Swiss. The European Hell is where the police are German, the lovers are Swiss, the cooks are British, the mechanics are French and everything is organized by the Italians. My mission of course is to disprove this, and I believe the environment is right. Currently the people holding power in AIFA, the Ministry of Health and the wider government are all visionaries, of the same generation and with the same mission, so today we have the capability to change the situation and make Italy a country which is known not only for its excellent researchers and food, but also for its excellent organization.