The provision of local healthcare services is an important topic for the Recovery and Resilience Facility (RRF) launched by the European Union and is deeply rooted in the strategies of the National Recovery and Resilience Plan (PNRR) that Italy implemented to face the serious healthcare, economic and social crisis caused by the pandemic since the first months of 2020 .
Looking at the work completed in the healthcare sector- one of the three departments that were operated on, together with education and mobility- in the 72 pilot areas that the National Strategy for Inner Areas (SNAI) focused on might help to discover more effective ways to implement such strategies, especially in relation to the PNRR Missions that are- directly or indirectly- linked with that subject .
“Inner areas” refer to locations that are significantly distant from centres that provide essential (education, healthcare and mobility) services, are rich in natural and cultural resources, and are very diversified- naturally or as a result of centuries of human activity. Roughly a quarter of the Italian population lives in these areas. They account for over sixty per cent of the entire territory, which is divided into more than four thousand towns . The SNAI experience might provide a few helpful lessons to better organise the implementation of the reforms and investments concerning the reorganisation of the healthcare system, which are outlined in the National Plan.
New models for the provision of local healthcare services
Reorganising the provision of local healthcare services was one of the central themes addressed in the SNAI preparatory documents. As we know, this matter became drastically urgent during the pandemic and caused several issues. Back in the days (we are talking about the 2012-13 period) a “rationalisation” process was taking place in the sector and, even though on one hand it was restricted by the measures to contain public expenditure that were typical of that political period, on the other hand the demand for equal and quality provision connected to the right to health outlined in the Constitution could not be ignored. The population expressed this need, particularly the groups living in the inner areas of the Country.
At the time the matter was articulated based on two polarised themes. One acknowledged that the general epidemiological context had changed and that chronic conditions were more prevalent, also due to the population ageing. The other theme focused on the need to take the financial and human resources from hospitals, which cost too much and were not always the best way to meet new needs, and move these to local facilities to enable a more widespread delivery of social and healthcare services. However, the details of such a service provision model were yet to be defined .
The suburban nature of the territory or low population density- elements that were (and still are) typical features of the inner areas of the Country- obviously resulted in a less equal provision of local healthcare services. That was the case especially for areas where the intervention in question often caused the suppression of several “minor” hospital complexes, deemed to be inefficient and expensive, without the full implementation of a “leaner, more flexible and personalised” model for the provision of local healthcare services taking place.
The proposals outlined in the SNAI acted within this complicated context. Their objective was to design interventions able to provide new models for the delivery of local healthcare services that would be complementary to the ongoing reorganisation of the hospital network and also to prioritise the quality of service provision offered to citizens. Therefore the work focused on the role of pharmacies and the network of general practitioners (or freely chosen paediatricians) in small towns, the need to aim for innovative socio-healthcare facilities and models (such as wellbeing centres) and the new outlook on mobile healthcare services. It also focused on the growing attention placed onto integrating home-based support services and telemedicine, and the relevance of proactive medicine.
The SNAI objective was to design interventions able to provide new models for the delivery of local healthcare services that would be complementary to the ongoing reorganisation of the hospital network and also to prioritise the quality of service provision offered to citizens.
When sifting through the list of interventions described under the place-based approach of the SNAI it seems as though there are several examples of projects that are coherent with the objectives described above. I will mention three of these that were listed in the Technical Committee for Inner Areas (CTAI) report , which was submitted to the CIPE (Interministerial Committee for Economic Planning). One is the creation of a transactional care coordinating station based at the location subject to the Sangro-Aventino Territory Agreement, which would “become the centre of the whole system and the referral point for patients in need of support following a needs assessment” in the Basso Sangro Trigno area (in the Abruzzo region). Another intervention involves the creation of a community hospital in association with the Bisaccia multidisciplinary healthcare facility as well as the tele-radiology project- the construction of a hospital IT network for the Criscuoli di S. Angelo dei Lombardi hospital- in the Alta Irpinia area (in the Campania region). Finally, another project concerns the establishment of a single point of access for palliative care in the Castenuovo ne’ Monti district, the provision of two beds for high-level intensity care and spaces that are also equipped for the families. Additionally, the institution of the community nurse role and the related opening of a centre that “operates in cooperation with the other professionals of the area and the hospital” in the Appennino reggiano area (in the Emilia-Romagna region) . Overall, the resources invested on similar projects concerning the provision of local healthcare services account for roughly 10 per cent of the budget provided by the SNAI, which equals to approximately 1.2 billion euros.
The notion of proximity in the PNRR
In hindsight, the National Recovery and Resilience Plan that was submitted to the European Committee in April seems to be based on these same intervention directives.
In the Plan- which is based on the binary combination of reforms and investments- the matter concerning the provision of local healthcare services is described in Mission 6 (Healthcare) and- specifically in relation to inner areas- in Mission 5 (Special Interventions for Territorial Cohesion). The section to refer to in Mission 6 is titled “Component 1” and it is dedicated to proximity, facilities and telemedicine for the provision of local healthcare services. The main proposal of the reform it describes is to enhance “services that are close by” and to “define homogeneous structural, organisational and technological standards for the provision of local support services” (that are to be defined with a specific ministerial decree by the end of 2021). It also envisages an investment of roughly 2 billion euros to create- by the first half of 2026- 1,288 community hubs, facilities “that would host multidisciplinary teams of general practitioners, freely chosen paediatricians and specialised doctors, community nurses and other wellbeing experts and where social workers could work from as well”. They would constitute the single point of access “for multidimensional assessments (leading to socio-healthcare services) and other services to safeguard women, children and family units following a gender based approach to medicine”.
Another investment- 4 billion euros in this case- will focus on the enhancement of home-based support and telemedicine, so that homes can become the first place to receive care. The project aims to increase the amount of home-based support interventions and reach- by the first half of 2026- 10 per cent of the population aged 65 and over, in line with European best practice. The plan to achieve this is to activate 602 local coordinating stations, one per district, dedicated to “coordinating home-based services with the other healthcare services and ensuring continuous communication with hospitals and the network of emergency services”. Furthermore, another investment- that comes with a total public expenditure of one billion euros- envisages the creation of 381 community hospitals, meant as “healthcare facilities, that are part of the network of local services, intended for short-term stays and dedicated to patients requiring medium/low level clinical interventions and short-term hospitalisations”. Finally, Mission 5 outlines an 830-million-euro investment in enhancing community social support services and facilities of inner areas as well as consolidating the affiliated pharmacies of rural towns with less than 3,000 inhabitants in order to enable them “to manage local healthcare services”. This last intervention is expected to come alongside co-funding by private parties, which will amount to roughly 50 per cent of the public funding that is to be spent.
Another investment will focus on the enhancement of home-based support and telemedicine, so that homes can become the first place to receive care.
Overall, based on the strong analogy between the abovementioned interventions and the SNAI ones, it would be reasonable to view the experience of the inner areas as a valid forecast of the initiatives that were later adopted by the PNRR. Therefore holding on to the baggage of knowledge and- institutional, technical and admin- know-hows obtained in many territories might prove essential to ensure the effective implementation of the measures to strengthen the provision of local healthcare services, which we will need to put in place in the coming months to safeguard the future of wellbeing in our Country.
 The strategies to enhance the provision of local healthcare services in response to the various issues with the Italian National Healthcare System- that were caused by the two viral “waves” that impacted our Country, hitting particularly hard the regions where the system “seemed” to be stronger- are illustrated in Mission 6 of the National Recovery and Resilience Plan (https://www.governo.it/it/articolo/pnrr/16718), which Italy submitted to the European Committee at the end of April 2021. The PNRR mobilises roughly 230 billion euros towards investments and reforms; approximately 20 billion euros should be utilised in relation to this subject.
 The National Strategy for Inner Areas (SNAI) experience- a pilot experiment inserted in the Framework Financing Agreement between Italy and the European Union on the public expenditure of the 2021-2027 period in line with the EU Cohesion Policy- is illustrated in every detail on https://www.agenziacoesione.gov.it/strategia-nazionale-aree-interne/. The website collects all the relevant information on both the preparation process and the implementation phases, which approximately 1,066 Mayors from our Country were involved in.
 Now there is a lot of literature available on the topic, even divided based on the individual intervention sectors of the SNAI: mobility, education and healthcare. For a general overview please refer to the numerous studies conducted by the Public Investment Evaluation Unit (UVAL) of the Council of Ministries and the large collection of technical documents that can be downloaded from the Government website on the following link: https://www.agenziacoesione.gov.it/strategia-nazionale-aree-interne/documentazione/
 This debate is present- though not explicitly- in many indications that the Ministry of Health outlined in the guidelines for place-based strategies, which can be downloaded from the following link: https://www.agenziacoesione.gov.it/wp-content/uploads/2020/07/Linee_guida_Salute_12_06_senza_mappa.pdf
The report, together with the others prepared by the Ctai, can be consulted in the aforementioned documentation section of the institutional website dedicated to SNAI: https://www.agenziacoesione.gov.it/strategia-nazionale-aree-interne/documentazione/
 The other relevant interventions can be found in the CIPE reports of 2018 and 2019 or in the “program agreements” that are published on the website of the Territorial Cohesion Agency (according to the latest updates available the details of 50 projects out of 71 have been defined): https://www.agenziacoesione.gov.it/strategia-nazionale-aree-interne/strategie-darea-e-governance/