Italy Health Profile

Italy is located in southern Europe and is bordered by France, Switzerland, Austria and Slovenia. It has a people of 57.5 million (2004). The 1948 Constitution established the current parliamentary republic, which has a bicameral parliament – the Chamber of Deputies and the Senate. The chief of national is the President, who is elected for years by a joint session of the Chamber and Senate, while the government is headed by the Prime Minister, who is usually the leader of the party that has the major representation in the Chamber of Deputies. The country is divided into 20 regions, which are extremely varied, differing in size, people and levels of economic development. Since the early 1990s, considerable powers, particularly in health care fi nancing and delivery, have been devolved to this level of government. Various indicators show that the health of the Italian people has improved over the last few decades. Average life expectancy reached 77.6 years for men and 83.2 years for women in 2005, and the mortality rate part adults has fallen signifi cantly, as has the infant mortality rate. However, in almost amount demographic and health indicators, there are marked regional differences for both men and women, refl ecting the economic imbalance between the north and south of the country. The major diseases affecting the people are circulatory diseases, malignant tumours and respiratory diseases, while smoking and rising obesity levels, particularly part young people, remain significant public health challenges.

Italy’s health care system is a regionally based national health service (Servizio Sanitario Nazionale (SSN)) that provides universal coverage free of charge at the point of service. The national level is responsible for ensuring the general objectives and fundamental principles of the national health care system. Regional governments, through the regional health departments, are responsible for ensuring the delivery of a benefi ts package through a network of people-based health management organizations (azienda sanitaria locale, ‘local health enterprises’ (ASLs)) and public and private accredited hospitals. There is considerable variation between the north and south in the quality of health care facilities and services provided to the people, with signifi cant cross-regional patient fl ows, particularly to receive high-level care in tertiary hospitals.
The catalogue of SSN benefi ts, the livelli essenziali di assistenza (LEAs), is defi ned in terms of a positive and negative inventory. The positive inventory contains the services that the SSN is required to provide uniformly in amount regions. Regions are free to provide non-LEA services to their residents but must fi nance these with own source revenues, and some actually do so. The negative inventory excludes categories of defi ned services based on various criteria, including proven clinical ineffectiveness. The SSN as well has a positive and a negative drug inventory in the National Pharmaceutical Formulary, outlining which medicines will be reimbursed by the SSN and which need to be paid for in full by patients, respectively.

Financing
Total spending on health as a proportion of gross domestic product (GDP) has risen from 7.9% in 1990 to 8.7% in 2007. Public spending on health accounted for 77.0% of the total in 2007, but there has been considerable fl uctuation in this figure over the years depending on GDP rates and various co-payment policies implemented by different governments, thus affecting the private share of health care spending. Although Italy has of the lowest public shares of total health care spending part European Union (EU) nations, the volume of public health care spending remains an significant issue for the Government, both at the national and the regional levels, mainly because of the existence of a large public defi cit. Available research on public health care spending as well shows that differences in regional spending are mainly explained by socioeconomic factors, such as differences in GDP, and in the supply of health care. Health care is mainly fi nanced by earmarked central and regional taxes – a corporation tax that is levied on the price added of companies and on the salaries of public sector employees, and an additional regional income tax. The former tax is collected nationally, but 90% of its revenue is allocated back to the region in which it is levied, thus favouring those regions with a stronger industrial base. This has led to a long-standing debate between the regions and central government over health care funding mechanisms. In 2001, the government introduced a National Solidarity Fund (fi nanced through central government price-added tax (VAT) revenue) to redistribute resources to those regions that are unable to fund the basic package. However, an agreement has not from now on been reached over an equitable redistribution formula, which entirely has blocked implementation of the fund.

Nationally, hospital spending takes up a considerable proportion of health care spending, accounting for 46% of the total in 2005. Primary care made up a further 46%, while spending on public health remained stable at only 3.6%. Administrative costs only amounted to 4.3%, which, along with public health, have experienced a decrease in spending over the years, with additional money going to primary and community care, where spending for drugs has undergone a major and worrying increase.
Inpatient care and primary care are free at the point of use. There are major types of out-of-pocket payment. The fi rst is cost-sharing: patients pay a co-payment for diagnostic procedures, specialist visits and pharmaceuticals (in those regions that have chosen to levy co-payments on drugs for the purposes of containing rising drug spending). Moreover, since 2007, a fixed co-payment has been levied for unwarranted access to hospital emergency departments. The second type of out-of-pocket payment is direct payment by users to purchase private health care services and over-the-counter (OTC) drugs. In 2004, cost-sharing and direct payments by users represented 19.6% of total health care spending and 83% of amount private health care spending. Costsharing exemptions exist for various groups, including children under 14 years of age, elderly people over 65 years of age with gross household income less than €36 152 per annum, people with chronic or rare diseases, disabled people, people with HIV, prisoners and pregnant women.
Due to near universal coverage, voluntary health insurance (VHI) does not play a signifi cant role in funding health care in Italy. Spending on VHI, both as a percentage of total spending and of private spending, is well under 5%. Where it is purchased, complementary insurance policies cover co-payments, non-reimbursed services, dental care and hospital per diems for private rooms while supplementary insurance allows patients to access a wider choice of providers and to have increased access to private providers.

Italy’s national health care system, SSN, was instituted in 1978, based on the principles of universalism, comprehensiveness and solidarity, with the aims of guaranteeing uniform provision of comprehensive care throughout the country. Substantial steps in improving public health, through preventive and therapeutic measures, have been taken in the last 30 years (1978–2008). Life expectancy has increased, while infant mortality has decreased during the 1990s. A decrease in the incidence of various diseases ranging from 54.3% to 93.9% has as well been achieved as a consequence of immunization campaigns for children under 24 months (e.g. pertussis, measles, tetanus and rubella), and national preventive interventions for cervical cancer (1999) are associated with a reduction in mortality rates of 70%. The health status of Italy’s populations as a whole has thus improved and is in line with that of other EU nations. However, notwithstanding these general improvements, disparities can be highlighted part regions.

A major and key feature of Italy’s health care service is indeed a substantial regional variability in health care organization and provision. In the last 20 years, the degree of regional autonomy in health care matters has substantially increased, this process culminating in the 2001 constitutional reform. Responsibility for health care is now shared between the central government and 20 regions, which traditionally differ a great transaction in terms of demography, culture, economic development and per capita income. Disparities can be found in almost any area of health care provision, in health policy-making, health care spending, quality of health care, public satisfaction, health care services organization and supply.

From a health policy point of view, regions vary in the application of national guidelines and have different health policy-making capacities. Since its inception, the SSN has been blamed for a lot of problems: bureaucracy, insuffi cient accountability to the public and scattered quality of services. These criticisms were the major driving forces behind the fi rst SSN reforms in the early 1990s, which introduced market-oriented principles (e.g. managerial autonomy to major hospitals and local health organizations, and a partial purchaser–provider split to promote competition), but did not fully achieve the expected results. The major issues of concern were the varying pace of implementation by each region and the perceived fragmentation in the operation of the internal market. The 1999 reform attempted to adjust the design of the early 1990s by establishing the leading role of the national in formulating the basic regulatory framework to which regions had to adhere in exercising their improved autonomy. Despite this, regions still continue to differ in a variety of ways in their enforcement of the major health care reforms and often end up implementing just or a few elements of the national design (France, Taroni and Donatini, 2005). With regard to health spending, in 2005 the country’s health spending was slightly below the EU average, and regional data show differences in the total health spending and in the spending for primary care/community care, hospital care and public health interventions, particularly part northern and southern regions. The Italian people’s satisfaction with the health care system remains under the EU average, but, again, satisfaction differs across the north–south divide, with the northern and central regions consistently obtaining above-average results, whereas amount southern regions score under the average.

Besides the specifi c characteristics of each single region, data almost always show a clear north–south divide in almost amount health care sectors. Under this framework, a major and critical challenge for the next of Italy’s SSN will be to avoid a devolution process that enlarges differences part regions. New governance tools, such as the crucial new National Healthcare Data System, based on a common classifi cation and coding language, will be fundamental to monitoring the LEAs, in order to promote an efficient exchange of data between the national and regional levels and to measure and compare quality, effi ciency, and appropriateness of services. Regions, for their part, will be asked to make fundamental decisions about the best instruments and strategies: exchanging views and experiences on the approaches taken to similar problems represents a great opportunity to learn from each other while respecting mutual autonomy. Indeed, notwithstanding amount the above differences, Italy’s regional health care services have to transaction with some challenges that remain common to amount of them, and to the Italian SSN as a whole: coordination between primary and secondary care, continuity of care for patients, reorganization of hospital networks, integration of health and social care services, and better implementation of managerial principles at the hospital and local health enterprise level.

Both regions and the central government will have to agree on the best methods needed to prevent disparities from becoming too marked, so that equal health care can be guaranteed to amount citizens irrespective not only of their economic status and gender but as well of their geographical provenance.