The mayor of Isernia, Piero Castrataro, is spending these cold nights in a tent in front of the Ferdinando Veneziale hospital. This symbolic and radical gesture is a protest against the progressive defunding of public healthcare and the proposed rationalization of Molisani healthcare services envisaged by the 2025-2027 Healthcare Operational Plan.

On the one hand there is the protest of a territory worried about the future of its essential services, on the other the Molise Regional Health Authority and the commissioner technicians who do not give in, appealing to the safety criteria linked to the minimum performance and activity thresholds established by national regulations. To put it simply: large volumes of operations in a few more specialized facilities with better outcomes and closing small local hospitals deemed unsafe.

A healthcare system in permanent emergency

To better understand the issue in a general framework, we must take a few steps back and talk about the Molise healthcare system which has lived, for over fifteen years, in a condition of exceptionality. In 2009 the State, during the Berlusconi IV government, intervened because the healthcare accounts were in the red and placed the Region “under guardianship”, imposing strict rules to save money. Since then the main objective has no longer been to improve services, but to spend as little as possible, and this logic has blocked hiring, investments and autonomous choices, leaving Molise healthcare in a sort of permanent emergency. The commissionership, born as an extraordinary tool, has transformed into a structural structure that has progressively weakened the ability of the public system to respond to the needs of a population residing in a complex territory.

Over the last twenty years, the Molise Region has seen alternating administrations with different political colors with a clear prevalence of centre-right but the management of healthcare, given the long phase of commissionership, has often placed the issue of delegations not directly in the hands of a single regional councillor, but as a shared responsibility between the president, the council and the central commissioner structure, with councilors appointed on the basis of the political coalitions in question.

ASReM is the accredited private sector that is growing

The regional public health service of Molise is headed by a single company, the Azienda Sanitaria Regionale del Molise (ASReM), which manages hospitals, districts, territorial medicine and emergency-urgency. However, alongside ASReM there is an accredited private sector that has taken on an increasingly important role over the years. Structures such as the IRCCS Neuromed in Pozzilli or the Responsible Research Hospital in Campobasso guarantee highly specialized services. This balance creates a healthcare system that remains public in principle but which, in reality, increasingly depends on the private sector with agreements to cover strategic sectors.

The Molise hospital network is organized according to the Hub & Spoke model (central and peripheral hospitals). The regional hub is the Antonio Cardarelli hospital in Campobasso, home to the first level emergency and urgency department and reference centre. The hospitals of Isernia and Termoli play the role of spokes, guaranteeing first aid and basic activities but depending on the hub for more complex emergencies.

One of the arguments most used by commissioners and ministerial technicians to justify the revision of the Molise healthcare network, by removing services from the Isernia hospital, concerns the alleged relationship between the number of hospitalizations carried out (haemodynamics and birth point) and the quality of care. According to this line of reasoning, codified in Ministerial Decree 70/2015, there is a correlation between volumes of activity and better clinical results. What does it mean? That facilities that treat a greater number of cases tend to have better outcomes and a lower risk of complications than those that treat few. So it wouldn’t be safe to keep the haemodynamic clinic and birth center open in Isernia?

In some areas, such as major surgeries or complex interventions, this association is documented by the scientific literature and is invoked to guide the rationalization of hospital networks. The commissioners, following the law, appeal to these criteria. But there is also a flip side to the coin; that is, the conditions of accessibility to services and the difficult demographic conditions that have an impact. Let’s take the case of hemodynamics which, for those who don’t know, is the place where you go when the heart is in serious danger, especially during a heart attack. It is used to see if the arteries of the heart are blocked and, if they are, intervene immediately. The doctor inserts a very thin tube into an artery in the arm or groin, reaches the heart, looks where the blood does not pass and places a kind of mesh (the stent) to reopen the blocked vessel. This procedure is time dependent and every minute lost means more damage to the heart. This is why having nearby hemodynamics can make the difference between saving yourself, being left with serious consequences or dying. This is the political and clinical crux: quality assessment is built on numbers, but also on the real context in which those numbers are produced.

The hemodynamics of Isernia

In 2024, the haemodynamics of Isernia, in the very hospital currently manned by the Mayor, had already ended up at the center of attempts to downsize or merge, justified precisely by the failure to reach the safety thresholds. But the commissioner structure and the Region in the 2023-2025 Health Operational Program have maintained three hemodynamics centers in the regional territory (Campobasso, Termoli and Isernia), with a commitment to verifying sustainability 24 hours a day, seven days a week. Reason for the decision? Precisely the orographic and demographic characteristics of Alto Molise, where the so-called golden hour for acute myocardial infarction would risk being compromised by too long journeys. So the question is: what has changed since then?

The philosophy of “one excellent hospital is better than many mediocre ones” is acceptable but it only makes sense if citizens have quick and safe alternatives to achieve that excellence. In other words, if Isernia could not guarantee certain services because it is below the threshold, the problem would not be the threshold itself but the difficulties of quickly reaching another facility that meets the standards. In the Molise context, where the fast medical transport network is not fully structured and the air ambulance depends on agreements with nearby regions, the distance of 5060 minutes to centers such as Campobasso can turn into a very high price to pay both for mothers in labor and for patients with time-dependent emergencies.

The paradox between accessibility and excellence

Also at the Venetian hospital in Isernia, data from the Molise health company indicate that the birth center carries out a number of births lower than the minimum threshold of 500 births/year currently recommended by the StatoRegioni Agreement of 16 December 2010 to guarantee safety and quality of care in birth centers. The threshold of 500 births per year is not arbitrary: it is designed to ensure that medical teams gain sufficient experience and that the facility is organized to adequately manage emergencies and complications. However, closing a sub-threshold department in the absence of rapid transport and autonomous emergency networks means transferring the risk to people and jeopardizing the right to health. And then the question becomes: does quality, even at the highest levels, still remain quality without accessibility? Mayor Piero Castrataro’s gesture certainly does not solve, on its own, the structural problems of Molise’s healthcare but it has the merit of bringing the issue back to its simplest and truest point: we need a welfare system that returns to occupying that “dead space” in people’s concrete lives.