Nuova pagina 1


Italian Home Contacts Credits ISSN
Urban Suffering Studies Center



Health systems are not designed for the needs of citizens

Nuova pagina 1


Benedetto Saraceno


The recent "Manifesto for an authentic Casa della Salute" organized by the Fondazione Santa Clelia Barbieri Vidiciatico, Bologna and the Casa della Carità in Milan describes the Casa della Salute as a place where "you can achieve a new community identity under the sign of an effective and involving welfare... both territorial and institutional resources are integrated in the construction and support of shared actions for health..." But was there any need for this Manifesto? The need, deeply rooted and urgent, stems from the fact that the health care system too often, if not perhaps almost always, DOES NOT achieve what the Manifesto recommends and promotes, IT DOES NOT combines health and rights, citizenship and welfare, human warmth and technical efficiency: IT DOES NOT achieve all this because in fact our health care system, like the majority of health care systems, is not designed for the needs of citizens.
"The growing influence of economic variables (as reflected in the requirements of the restrictive IMF's policies regarding social, educational and health rights) the assumption by the World Bank of the roles of the WHO in setting health priorities in terms of the economic compatibility of the costs of illnesses... have led to the disappearance of health as a right in favor of health care as a combination of accomplishments or rather as commercial goods "(Gianni Tognoni, Global Rights Report 2012, p.1083.) This "increasing influence" has not only a factual impact on the choices made by health care systems but permeates the culture and languages of health care diluting and dissolving the moral and technical strength of the vision of public health, transforming health into a commodity rather than a public benefit. Health is thus declassified from an unreserved right to a relative right: health policies and the organization of services are increasingly occupied with management and cost containment, and living instead of dying or feeling good instead of being ill become dependent variables (according to economic logic) rather than independent variables.

This reductive and neoliberal "view", however, is not represented as an ideological choice but is offered as "the reality": everyone slowly and unconsciously internalizes this logic as the only possible logic and so the inequalities are transformed (or rather, are artificially transformed) in an objective, inevitable reality, rather than simply representing the subjective choices of a political establisment. As a matter of fact it is not "reality" but an "ideology of reality" where you increasingly lose all the necessary elements for the capacitation of individuals (according to the opinion of Amartya Sen): these elements are essential for people to be capacitated in the progressive approprazione and conferment of the power to manage their own health (empowerment).
As a result of these three combined factors:
1. Changing the classification of health from absolute right to relative right
2. The internalization of the inevitability of inequalities
3. The lack of power to manage one's own health

Therefore, the offer of health is not designed to meet the needs of citizens but citizens must devise their own needs and adapt them to the possibilities offered by the health system: as Ugo Guarino, artist and graphic designer, said at the time of the first great battles in Trieste for the rights of psychiatric patients: if the patient's clothes of are too short it's not necessary to lengthen them, just shorten the patient.


This process of the gradual disappearance, not only of the right to health, but of health as a right, however, is challenged and weakened by some phenomena that become increasingly more pressing and crucial:

• Chronic diseases, namely chronic non-communicable diseases (such as cancer, diabetes and cardiovascular disease), persistent chronic infectious diseases (such as tuberculosis or HIV infection), mental illnesses, permanent physical disability) today represent 60% of all deaths and it is estimated they will constitute 78% of the "global burden" of all diseases in 2020. All these diseases although very different from one another have in common their persistence in time and therefore have in common the need of being taken in charge, of care, rehabilitation and assistance equally long-lasting in time and without doubt in non-hospital, non-medicalized settings.

• Massive demographic evolution (evident both in high-income countries and in large countries with large economies in expansion, (as in the case of India, China and Brazil), which increases the population of older people and consequently vulnerable older people.

• Massive urbanization which increases the phenomena of urban suffering. The urban population has grown significantly in the last thirty years: in 1975, 26% of the people in Africa lived in cities, today it's 39% and in 2030 it will be 63%; in Asia the increase will be from 29% to 64% and in Europe from 66% to 79%. The world is being transformed into megacities. The United Nations Population Fund (UNPF) estimates that 85% of the increase in the world's population over the next 30 years will occur in urban areas. The urban population in developing countries will increase from 2 billion in 2000 to 4 billion in 2030, while the general population of the globe will pass from 6 to 8 billion. Urban growth will be much more pronounced in smaller cities rather than in the megalopolis.

• The exponential increase of the 4 risk factors for Chronic Noncommunicable Diseases (tabacco, alcohol, unhealthy diet, physical inactivity). The increase of these risk factors is tied to a set of social determinants that combines poverty, low educational levels, social exclusion, urbanization, social inequality. The widening of the gap of social inequalities is dramatic and therefore the impact of social disease determinants grows and intensifies.

• Lastly, the ascertainment that 85% of the daily lives of people who suffer from a chronic disease (contagious or not) are lived outside the hospital: therefore hospital admission could become an infrequent event of limited duration. It should be noted that 70% of days spent in hospital in Europe occur in "emergency beds" and at least half of these hospitalizations are avoidable (they are revolving-door patients or with an insufficient and inadequate adherence to treatment, or simply elderly people living alone).

In brief, the challenge that these data and phenomena express is that basically the health system is NOT planned to respond to a reality, characterized by indispensable interconnections between patient and disease, between patient and the places in his daily life, between patient and family, between patient and the community to which he belongs.
The hospital system is basically designed for acutely ill patients and is hardly interested, aware, capable and consistent with the chronic needs expressed by many sick people; the hospital system does not communicate and is basically alien to the community. The technical excellence of the general hospital (when it exists) does not preclude an ontological alienation of the hospital towards the before and after of the inpatient and therefore when the patient is ill with a chronic disease he will find it difficult to find answers in the hospital consistent with his needs that exist in a continuum of before and after, where the hic et nunc of hospitalization for an acute exacerbation of his illness is only a fragment of a more complex human and clinical story.
Finally, do not underestimate the violation of the rights of citizenship that is produced in hospital and that depends on its institutional connotations which in many cases is evidence of the typical characteristics of the whole institution. In this case we are certainly not comparing the violence and misery of the psychiatric hospital with that of the general hospital but, nevertheless, we cannot ignore the frequent abusive excesses, objectifying, dehumanizing and, sometimes, violent that may be encountered even within the framework of a general hospital (do not forget the frequent use of physical restraint both in psychiatric wards and
in those that accept elderly patients and those that cause disturbance).
Of course, the crux of the answer to the question of care and assistance for people with long-term illnesses can not come only from a hospital even when reformed and made more consistent with the needs of this enormous population: the main issue is for the massive development of a medecine for the community, of strategies for prevention, cure, rehabilitation and assistence centralized in and on the community.
We can, albeit schematically, consider some strategies as necessary adjustments to the actual state of the health services:

1. the systemic and systematic development of "Person-centered Medicine," a theoretical and practical model to which reference is made continuously and ritualistically without grasping the systemic implications. "Person-centered medicine" can not and should not be seen as a "nicety" or as a pleasant, decorative element in the way health care services are offered but as a powerful determinant of outcome and, at the same time, a concrete implementation of a policy for the rights of citizens who seek and receive health service benefits.

2. investigation of all the failures of a full and proper adherence to treatment that should be taken into consideration as important indicators of the inadequacy of the system (it is necessary to analyze and evaluate both the phenomenon of the chronically ill who have "disappeared" from monitoring systems and "revolving door" cases as possible indicators of failure).

3. the development, both at the system level and the training level of health workers, of strategies that promote and lead to real empowerment (for example, the geographic and temporal access to the offers of health decided on together with the local community).

4. the development of preventive and curative measures in the Community. In this regard, it should be clarified once and for all that Health and Community Medicine is obviously much more than just the availability of outpatient services but it is also much more than an efficient General Practice system. In fact, Health and Community Medicine involves the activation of:
• intersectoral resources, of skills and actions for health
• flexibility and mobility of budgets that should be centered on and accompany the needs of individual users (person-oriented) rather than being centered on performance (provider-oriented). In other words, the historical logic of the psychiatry of Trieste whereby "the budget follows the patient" and is not "attached" to performance (bed, medical assistance, etc.) should no longer be a brilliant intuition of a health policy reserved for a specialized practice of excellence, geographically circumscribed but it should become the current policy of the health care system.
• Horizontal coexistence of top level and specialized performances in the framework of Health and Community Medicine. Especially concerning chronic illnesses it is necessary to rethink and radically overcome the separation between Primary and Secondary Care (ie between Primary Care and Specialized Medicine), in this regard see the innovative document drawn up by the WHO together with the Gulbenkian Foundation (WHO-Gulbenkian, 2014).

In conclusion, it comes down to giving back RIGHTS a role and a central location in the conception, planning and organization of health systems: it is urgent and necessary to stop considering rights as "desirable factors" of the offer for health on behalf of health systems but as substantive INDICATORS (or "measures") of policy, planning and provision of health and health care.


World Health Organization- Fundação Calouste Gulbenkian. Integrating the response of health systems to mental disorders and other chronic diseases. WHO, Geneva, 2014.



By the same authors:                Dancing the samba while piloting a jet plane   SouqBiblio: annotated international bibliography*  A Return to the Way leading to Happiness   Aporeia of empowerment  Deconstructing the paradigm of "migrant emergency"  Defend the ways of liberation  Describing reality but also changing it  Educate in complexity  Empowerment  Global health, local health: a paradigm of the failures of globalization   Reject Ferocity, Not Migrants  Souqbiblio (number 1)  SouqBiblio: international annotated bibliography number 8  SouqBiblio: international annotated bibliography*  SouqBiblio: internazional annotated bibliography (number 6)  SouqBiblio: annotated international bibliography  SouqBiblio: annotated international bibliography  SouqBiblio: annotated international bibliography  SouqBiblio: annotated international bibliography  SouqBiblio: international annotated bibliography (number 5)  SouqBiblio: international annotated bibliography (number 3)  SouqBiblio: International annotated bibliography (number 7)  SouqBiblio: internazional annotated bibliography (number 4)  SouqBiblio: References (number 2)  The association Poverty - Mental Disorders and its implications for outcome and care provision   The Confusion to be managed  The paradigm of urban suffering  Time of Siege  Urban Resistance  Verbal violence and social paranoia 

Bookmark and Share

Center for urban suffering

The study centre wishes to study the phenomenon of urban suffering, in other words the suffering that is specific to the great metropolises. Urban Suffering is a category that describes the meeting of individual suffering with the social fabric that they inhabit. The description, the understanding and the transformation of the psychological and social dynamics that develop from the meeting of ...

Who we are

The Urban Suffering Studies Center - SOUQ - arises from Milan, a place of complexity and economic and social contradictions belonged to global world.Tightly linked to Casa della Carità Foundation, which provides assistance and care to unserved populations in Milan (such as immigrants legal and illegal, homeless, vulnerable minorities), the Urban Suffering Studies Center puts attention on ...


Centro studi Souq Management commitee: Laura Arduini, Virginio Colmegna (presidente), Silvia Landra, Simona Sambati, Benedetto Saraceno ; Scientific commitee: Mario Agostinelli, Angelo Barbato, Maurizio Bonati, Adolfo Ceretti, Giacomo Costa, Ota de Leonardis,  Giulio Ernesti, Sergio Escobar, Luca Formenton, Francesco Maisto, Ambrogio Manenti, Claudia Mazzucato, Daniela ...
< Ultimo aggiornamento
  Editorials   Theory waiting for practice   Practice waiting for theory   Papers   References  

Nuova pagina 1

ISSN 2282-5754 Souquaderni [online] by SOUQ - Centro Studi sulla Sofferenza Urbana - CF: 97316770151
Last update: 26/11/2020

[Area riservata]