Health Is A Political Choice – But Should Health Officials Be Politicians Or Professionals? Inside View 19/11/2019 • Armando Bartolazzi Share this:Click to share on Twitter (Opens in new window)Click to share on LinkedIn (Opens in new window)Click to share on Facebook (Opens in new window)Click to email this to a friend (Opens in new window)Click to print (Opens in new window) Italy’s former Undersecretary of State for Health, Armando Bartolazzi, discusses the implications of recent moves to replace the head of the Italian Medicines Agency (AIFA), based on political considerations of the a new Health Minister. “Health is a Political Choice” said WHO Director-General Dr Tedros in his keynote session at the World Health Summit, Berlin, 29 October 2019. I fully support this statement. However, what about Health Officials? There is a long tradition in Italy of politicians appointing key health officials for the National Health System (NHS). However, I was part of an initiative in 2018 to change that system and ensure that key appointments in the health system were based on technical experience and merit, rather than political connections. Now, that initiative may be reversed by the new Health Minister, Roberto Speranza – to the detriment of the Italian public as well Italy’s image in international health leadership. In February 2018, just before the general political elections, I was approached by top representatives of the fast-rising 5 Stars Movement to discuss my possible involvement within the government if the movement won the elections. I had a positive impression from Luigi Di Maio, the soon-to-become Vice Prime Minister when we met in front of the hospital where I worked in Rome. The message was crystal clear: “please help us to promote and guarantee that meritocracy, expertise and competence become the only criteria behind the appointments of high-level managers in the health sector”. Armando Bartolazzi, former Italian Underscretary of State for Health The 5 Stars Movement did win the elections shortly thereafter, and I took on the role of Undersecretary of State for Health for the new Government, between June 2018 and August 2019. I immediately started working to use a different approach in selecting top health officials. The first selection coming up was that of the Director General of the Italian Medicines Agency (AIFA). Based on my professional experience at the Karolinska Institute of Stockholm, Sweden, I proposed to the Health Minister Giulia Grillo to use a blind international selection process, something well established abroad, but never used before in Italy, instead of the classical Italian selection process known as “concorso” which generally doesn’t guarantee an independent judgment based on meritocracy, but fits very well with the pre-defined political inclinations of ministers in charge. Around 100 CVs were received. Three independent international experts, including Sir Andrew Dillon, one of the most prominent experts in the pharmaceutical sector, were recruited to screen out the candidates and make their recommendations. After three independent evaluations, Dr Luca Li Bassi, then head of a health sector strengthening initiative at the International Atomic Energy Agency, was finally included among the top candidates. This was based on his strong and wide experience related to medicines assessment, procurement, access and delivery in numerous international agencies, including the Global Fund to Fight AIDS Tuberculosis and Malaria. These activities had led to concrete achievements influencing national as well as global markets and achieving impressive results when addressing major challenges in this sector. With an MD from Milan University, and degrees in both Management and Public Health obtained in New Zealand, Dr Li Bassi made a convincing final interview with the Minister. No one in the Ministry knew him directly and he did not know any of us, considering that he had spent most of his professional career abroad, working in three different continents for the previous 25 years. With this process, we had effectively started a new approach, based on the principle that making health a “political choice” also must include choosing to free up the National Health System from political influences when selecting its top management. It includes recognizing that better health for people, Universal Health Access and greater health gains based on available resources cannot have a political colour – but need to be anchored in professional, evidenced-based decisions, and in the case of medicines regulation are also among the most technical issues faced by health policymakers. We explained this principle in a letter published in The Lancet and were proud to have made this change for the first time in our country, where the inequalities in the health system are still growing. This may arguably also be attributed to the various political influences at local, regional and national level that are diverting health investments to other political interests, regardless of the best interests of their constituents. A New Approach Brings Results Key achievements reached by AIFA in the past year are quite clear for any outsider. A few weeks after his nomination, the new DG Li Bassi, was able to negotiate the core of the historic agreement with the Italian pharma lobby group (Farmindustria) that unlocked € 2.4 billion for the national health system, a deal that had been awaited since 2013! He then went on to negotiate consensus among 192 World Health Assembly (WHA) Member States on what the Chair of Committee A had declared to be “the most contentious issue in global health” with adoption last May of the WHA Transparency Resolution [Improving the transparency of markets for medicines, vaccines and other products]. I witnessed his hard work arguing on technical grounds with delegations from all over the world, and I was honoured to speak in the Plenary of the Assembly and receive the chilling applause and hugs of hundreds of delegates. Luca Li Bassi holding Italy’s placard at the 72nd World Health Assembly with other lead co-sponsors of the WHA Transparency Resolution. It was an historic moment – more so since Italy has never been able to take a leadership role before in the World Health Assembly. At national level, he then successfully raised the issue of medicines shortages, implementing measures that have since been taken up as examples by other EU countries, such as the need for national stockpiling, longer advance notices by producers, and export bans and penalties in case of lack of supply, all focused to protect public health. As a matter of fact, I note that nobody was talking about the emergencies caused for many national health systems by shortages in the international fora only 6 months ago, while now this has become a priority issue in the European Union. It was also declared a priority by the International Coalition of Medicines Regulatory Authorities (ICMRA) at its last summit, which was hosted for the first time in Rome last month at the behest of the AIFA DG. In addition, Li Bassi led AIFA to negotiate under an innovative “payment for results” scheme, the reimbursement of expensive new CAR-T technologies for treatment of leukaemia (and likely other type of cancers in the near future) making finance for such treatments sustainable for the NHS, and rewarding the suppliers only when the treatment is successful. In order to make sure that this technology is effectively adopted by the NHS, AIFA also gathered experts nationally and internationally to discuss how the Ministry could invest in independent facilities that in the future will be able to develop production capacity in public “cell factories” around the country. The Ministry has now decided to allocate €60 million for the next year on this project, another visionary move that would not have been possible without the catalysing efforts of AIFA. Back to Politics Again in the New Italian Government? With the new government coming into power as result of the political crisis last August, Italy now has a new Health Minister, Roberto Speranza, representing a small party from the far left (Article One). With his decision to announce the recruitment of a new DG in AIFA, he has effectively given into the principle of awarding this sensitive position to someone based on his politics, rather than professional skills. This will also bring to the national regulatory authority for medicines, a highly technical and supposedly independent agency, the third DG in three years. Yes, health is a “political choice” – But as health professionals, our aspirations and concrete accomplishments in delinking politics from management of the health system has been trashed at a blink of an eye. Most importantly, all the ground-breaking work that has been done by AIFA under the current leadership over the past year both in the national as well as international fora is threatened. It could vanish, or in the best case suffer delays, ultimately to the detriment of people’s health. It is obviously the right and responsibility of any new Minister to revise priorities and indicate objectives. It is the role of health managers as the technical and operational arm of the NHS to then implement those objectives, and to become accountable against these new priorities, in terms of performance. So why not take such approach, giving AIFA’s current DG the opportunity to respond and be accountable? Where is the need to go back to the old logic of political appointments and appointees? What can a political element provide to technical work that has not been delivered in the past year? Why do meritocracy and competence have to be traded off with politics? As an example, the head of the European Medicines Agency does not normally change after the EU elections and the establishment of a new Commission, was was just experienced recently. As a health professional myself, I doubt that the decision taken by the new Minister is the best line of action for the interest of patients and the public-at-large. Italy’s NHS needs good managers, strong leaders in the global arena and undisputed focus on the best interests of the whole community that it is supposed to serve. ___________________________________ Armando Bartolazzi, MD, is an oncologist-pathologist by training. He served as former Italian Undersecretary of State for Health between June 2018 and August 2019. He is currently Professor of Pathology (first level Dirigente) at Sant’ Andrea University Hospital, Rome, Italy, and Research Associate at the Department of Pathology-Oncology, Karolinska Hospital, Stockholm, Sweden. Since 1987 he has worked in the field of cancer research and diagnosis Image Credits: @Armando Bartolaz, HP-Watch/E Fletcher. 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