One of the main dynamics of change in the Italian welfare system since the 1970s has been the restructuring of decision-making processes to encourage participation. Today, the new millennium presents evidence of the growing protagonism of the public service authorities in this process. This leading role heralds ambivalent outcomes; although it expresses an attempt to retain the public service’s role as guarantor of fundamental rights, it also lends itself to processes of de-accountability of the same public body. Twenty years after the reform of Title V of the Italian Constitution, this article examines and compares the institutional representa tions of the role of citizens-users/patients in five regional health systems in Italy. Our study, conducted using the Delphi technique, identified the instruments currently applied and the impact of the 2020/2021 Covid pandemic on the regional systems. The results highlight some interesting experiments in the direction of overcoming the traditional “democratic deficit” of the health system; even if the organizational, communicative, cultural and training challenges of “competent” citizens and communities remain open and further accentuated after the Covid-19 pandemic.
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