Germany and Italy: Federalism and Regionalism
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Germany and Italy are two countries which are, historically, examples of ‘conservative and strongly “corporatist” welfare states’ (Esping-Anderson 1990:27) even if this is no longer the case for Italy in the field of health care. Germany is the European country with the strongest Rechtsstaat tradition with the state as the point where the federal interests are integrated and underpinned by an extensive legal framework (Pollitt and Bouckaert 2000:53). This contrasts markedly with the Italian political traditions and has implications for the health service in each country as well as their medical and nursing professions. Italy had for over thirty years a nationalised health service, which would seem to suggest it has more in common with the UK model. As will be explained later, this would be an inaccurate assumption for a range of historical, cultural and political reasons. On the other hand, in relation to Germany there is an intriguing symmetry between the two health systems. Germany is formally decentralised (federalism) but subject to centripetal forces of increasing federal state regulation. Italy has had a formally centralised health system that is subject to strong centrifugal forces of regionalism. On the other hand, the professional organisation of hospital doctors and nurses in the two countries is rather less symmetrical. German hospital doctors accept their professional responsibility and zealously guard their rights of self-regulation. Italian hospital doctors would appear to enjoy less autonomy and are confronted with cross-cutting commitments of a particularistic and clientelistic kind that compromise the profession’s ability for self-regulation. The Italian nursing profession appears to have greater autonomy and status than its German counterparts, but the differences between the formal professional organisations and the work situations of nurses within and between the two countries are more complex than they first appear.
KeywordsSickness Fund Hospital Sector German Hospital Hospital Doctor Local Health Unit
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