Beyond Public and Private. Social Innovation in Healthcare System

In recent years, both the "myth" of public control over healthcare and the "myth" of the dynamism and high quality of health services managed by private sector have shown their weakness. As it is known, the creation and consolidation of these “myths” concerns country-specific peculiarities of the different healthcare systems. In particular, the “myths” refer to the dominance of a professional institutional logic typical of the public intervention or that headed by market forces and the intervention of private business in the health management and social issue. Mintzberg and other scholars such as Porter and Teisberg (2006), have analysed weaknesses and strengths of these myths in the health systems of several countries highlighting inefficiency of both solutions entirely "government-controlled", and "market-controlled". Generally there are many studies that have shown both state and market failure in the management and financing of the social economy (e.g. Cheng and Mohamed 2010; Murray et al. 2010; Noya 2010; Phills et al. 2008). In Italy, the need to overcome these approaches and to explore new organizational models is related to two main reasons. On the one hand, in the last decade, we are looking at a stunning growth in the demand for healthcare; on the other hand, market dynamics have a strong impact on the healthcare services. We look at a steady increase in private health spending, € 32.971 bn in 2014 with an increase of 2% compared to 2001 (22,4% on the operating health expenditure of NHS that in 2014 was € 114,057 bn) (Armeni and Costa 2015) which inevitably has a negative impact on a large part of the population. Regarding to the latter aspect, in 2014 the percentage of out of pocket (private spending not covered by any insurance type) on the total spending is one of the highest in Europe, at about 22%, with € 33 bn (Del Vecchio et al., 2015). In addition to these two reasons, we add the radical change of public policies patterns, in order to respond to the welfare crisis (e.g. Cicellin and Galdiero 2009). In this context, new paths are increasingly arising traced back to the philosophy of low cost, low profit and light healthcare. Such experiences have been created to meet the social demand of health that cannot be completely satisfied either by the public health nor by the private. They are based on the bottom-up complex world of services and needs and can be labelled as social innovation models (Leadbeater 2007). In the healthcare field, all the European countries are giving relevance to the social innovation issue. The European Parliament published a series of documents underlying the strict need to create a new welfare system builded on the model of the Civil Economy, to recognize the crucial role of actors involved in the social economy sector and to take steps to ensure their development (see the Report on the Social Economy 2008/2250 of the Commission on Employment and Social Affairs). The aim of this chapter is to analyze the concept of social innovation in healthcare as an alternative path to the two “myths”. From our point of view, the paradigm of social innovation is the main key to understand the phenomenon of low cost services in healthcare. We are interested to shed light on the current experiences of low cost for healthcare in Italy, in order to understand organizational paradigms, motivations, services offered and arrangement, compared to the established “myths”. The recent evolution of the low cost services in healthcare are likely to be a very interesting opportunity for the development of social initiatives beyond public and private. Mintzberg talks about the "plural sector”, that is the social sector including associations, noprofits, cooperatives, etc.. The low cost services try to re-read the interconnections between public and private sector, profit and no profit, efficiency and equity, and appropriateness of care models. The main scope of low cost in healthcare is to overcome a context where the public segment operates in a totally separated manner from the private one, in order to create an interconnected healthcare industry, both in terms of objectives to be pursued (the best care of health with the collection of public and private resources available) and of operational activities (what happens in a segment positively impact on the other). This phenomenon goes through and beyond the debate on mutualism for integrative health. Actually, low cost services projects arise mainly for health specialist and are based on the ability to connect economic (in terms of efficiency), social (in terms of relationships), cultural (linked to values) and institutional aspects (in terms of social capital that is generated) (Rago 2012; Donati and Colozzi 2011).