We continue our series of in-depth commentary curated by Giulia Muratori, secretary of Libera San Marino.
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There is a word that, when talking about healthcare, we may have gradually stopped using in its deepest sense: social security. And yet it is precisely this expression that gives our Institute its name. That is no coincidence. Those two words embody a precise idea of society — the one with which San Marino chose to build its system of social protection.
Social security meant affirming a simple yet profoundly innovative principle: no one should be left alone in the most delicate moments of their life, whether they fall ill, have a child, grow old, lose their independence or need assistance. For this reason, health cannot be reduced to a hospital visit or a single medical service. It is something broader: it means caring for the person throughout their entire life, from prevention to treatment, from assistance to long-term care for those who are no longer self-sufficient.
It was with this vision that our ISS (Social Security Institute) was founded. And I believe that today, as we discuss how to make our healthcare system more modern and efficient, it is worth starting from here: from the meaning of that name and the idea of community it carries with it.
Today this model must come to terms with profound changes, and if we want to preserve it, we must have the courage to change it — to adapt it to a society that has changed significantly and make it capable of responding to new needs.
The population is ageing, chronic conditions are increasing, and a growing number of people need not so much a single medical intervention as ongoing care over time. This is why the debate on healthcare cannot be limited to how many hospital beds we have or how many procedures are carried out. We need to think above all about where and how we care for people.
The hospital naturally remains essential for emergencies, surgeries, acute conditions and specialist care. But not everything needs to end up there.
An elderly person with multiple chronic conditions, a frail patient or someone who is bedridden often needs, above all, continuity of care, regular check-ups and professionals able to follow them at home. The better community healthcare can provide these responses, the less the hospital is used for needs that could be addressed differently.
This is where the role of general practice becomes central once again. The family doctor cannot simply become a gateway for obtaining a prescription to access the next level of care.
They must return to being one of the key figures responsible for the patient’s overall care. This also means reducing the bureaucratic steps that today can needlessly lengthen care pathways. Technology and information-sharing should allow for simpler processes, in which professionals communicate directly with one another instead of constantly requiring the patient to act as an intermediary.
Strengthening community-based medicine also means valuing other professional roles. Starting with nurses, who could play a far greater role in monitoring patients with chronic conditions, in home care, and in supporting the elderly and those who are no longer self-sufficient. For some patients, a check-up carried out at home can avoid a difficult journey, a visit to a healthcare facility and, in some cases, even hospitalisation.
In Emilia-Romagna, for example, home care is provided by teams made up of doctors, nurses and social workers who work alongside the family doctor. “Case della Comunità” (Community Health Houses) bring together general practice, nursing and other local services, while “Ospedali di Comunità” (Community Hospitals) represent an intermediate level of care for patients who no longer need to remain in an acute hospital ward but cannot yet be properly cared for at home. The underlying principle is compelling: bring care as close as possible to the person, and reserve the hospital for what truly requires a hospital.
The issue of long-term care must also be approached within this same logic. Not everyone who needs prolonged assistance needs to remain in hospital. What is needed are community facilities and services capable of ensuring continuity between discharge, rehabilitation, ongoing care and, where possible, a return home.
A universal system must also be sustainable
Naturally, all of this requires organisation, staff and resources. The universality of the system and its economic sustainability are not opposing issues. A public service must make good use of its resources precisely in order to continue guaranteeing access to care regardless of people’s financial circumstances.
But efficiency cannot be measured as if healthcare were simply a collection of individual services. A hospitalisation avoided thanks to good home care, a frail person properly followed by community services, or a chronic illness caught before it worsens — these too are outcomes of a well-functioning healthcare system.
It is in light of these goals that the review of the ISS Organisational Charter (Atto Organizzativo) must be approached.
This is the vision of healthcare that Libera has always believed in. And ultimately, it is the very idea of social security that we want to preserve: a public and universal system, a public and universal system, in which access to care does not depend on anyone’s financial means, and which is able to accompany the person from prevention through to treatment and care.
To defend this model, however, we must today make it evolve: strengthening general practice, prevention, home care and community services, and avoiding concentrating on the hospital responses that could be better provided elsewhere. This is a direction also reflected in the choices being pursued by the ISS Executive Committee, and one that deserves to be supported and reinforced.
Places matter too
This change also requires adequate facilities. The new health centre in Borgo Maggiore is now close to opening, and work is beginning on the one in Murata. These are initiatives consistent with the idea of bringing general practice closer to where people live. At the same time, the expansion of the Casale La Fiorina care home is planned, adding around fifty new places for elderly people who are no longer self-sufficient, and the project for a permanent hospice is moving forward.
Within the hospital itself, a series of smaller but highly concrete interventions have also been prioritised: the oncology department, the new pharmacy, the blood-sampling area, the expansion of the Emergency Room waiting area, the new mortuary, and the endoscopy recovery room.
These are very different projects, but they share a common aim: improving the day-to-day experience of both those who use health services and those who work within them.
San Marino has a distinctive feature: a single Institute that brings together a very broad share of the population’s healthcare and social protection.
Thinking about the future of the ISS means, first and foremost, defending the principles on which it was built: universality, accessibility of care and the centrality of the person. This is the true value of social security — not simply treating illness, but preventing it, providing assistance, and accompanying people throughout their entire lives.
Defending these principles, however, does not mean leaving everything as it is. It means changing the system in order to continue guaranteeing them.
