MRIC Global Essay Contest: A look at the Italian Health System
Author: Cecilia Acuti Martellucci
Master’s Candidate at the Department of Global Health Policy, The University of Tokyo
In Italy, between 1985 and 2016, mean life expectancy rose from 75.5 to 82.5 years, GDP from 436 to 1,859 billion USD (with ups and downs), and public expenditure for drugs from 4.6 to 16 million USD. Healthcare expenditure in 2016 was 149,500 million euros, 8.9% of GDP. 112,182 millions came from the public sector ? a 42% rise from the 2002 figure, while 37,318 were private expenditure. The largest costs were curative and rehabilitative care, and drugs and medical equipment, respectively a 55% and a 21% of the total expenditure. Hospitals were the main providers of care, accounting for 45.5% of total current health expenditure. Comparatively, Italy’s per capita health expenditure in 2016 was lower than in other OECD countries: Italy was at 3,542 USD while the United Kingdom, Japan, Canada, France and Germany were between 4,000 and 5,000 USD.
Evolution of the Italian Health System
Article 32 of the Constitution (1948) reads: “The Republic protects health as a fundamental right of the individual and interest of the collectivity, and guarantees free cures for the poor.” Since then, the Health System has undergone four phases: 1. At first it was a Bismarck type, insurance-based system, until the establishment of the National Health System in 1978; 2. Universal coverage was achieved according to Beveridge’s Welfare State, but then hindered by the cost-containment measures of 1993; 3. The third phase saw promotion of efficacy, effectiveness and competitiveness in a system that is de facto “public”; 4. Last is the federalist development, started in 2001, that has allowed growing legislative autonomy on healthcare to the 20 Italian Regions.
In Italy healthcare is provided by the following structures: - Local Health Agencies, comprising Hospitals, Districts and the Department of Prevention; - Hospital Agencies (with their own Director and a DRG payment method); - Institutes for Cures with Scientific Character, clinical research hubs; - Private accredited structures with an agreement with Health Agencies. Some Regions have eliminated Health Agencies’ hospitals, and only entrust Hospital Agencies with all inpatient care, in a buyer-supplier relationship. Districts manage general practitioners and integration between social services, primary and specialist healthcare. The Department of Prevention promotes health in life and work environments, from vaccination and screening programs to hygiene and safety in schools, workplaces and restaurants.
Essential Assistance Levels
The risk of differences in healthcare between Regions is real, but controlled, since the State remains in charge of the Essential Assistance Levels (LEA): healthcare services provided to all citizens, for free or through co-payment, that have, for specific clinical conditions, scientific evidence of significant health improvements, consistently with financing. Regions are responsible for providing the LEA, and the State defines them based on the following principles: - personal dignity; - health needs; - equitable accessibility; - quality of care and appropriateness for the specific needs; - fair use of resources.
Monitoring and evaluation of outcomes
In 2010 monitoring of the quality of healthcare started with the National Outcomes Plan (Piano Nazionale Esiti, PNE), designed for performance evaluation of hospital and primary care through 166 indicators of outcome, process and volume. Results are available online to providers and citizens, updated yearly also in English. It is not entirely independent from the National Health System, but balances its institutional endorsement with the expertise of the professionals contributing to its development.
A personal view
The biggest shortcomings that I could notice in my clinical experience are defensive medicine, long wait times and inappropriateness. In Italy, wait times are exasperated by the reduced health personnel and by GPs’ excessive prescriptions to avoid medical errors. Such defensive attitudes are found in many other specialists too. Inappropriateness is instead driven mainly by the DRG payment system, which prompts doctors and administrators to choose the most expensive procedures instead of the most appropriate ones. On a different level are the disparities between Regions and hospitals, as recently outlined by the PNE. While the LEA mitigate these inequalities, patients that can afford to seek care in Regions that offer better health services keep leaving many more behind. I believe regulations to improve accountability and their systematic enforcement could represent an important step to counter these issues.
The Italian Health System produces relatively good results in terms of health outcomes and quality of care, but needs to address the widespread inequalities, the long waiting lists, the still inefficient monitoring, and the rising expenditure. For policy makers and health professionals wishing to make decisions based on cost-effectiveness, the use of Health Technology Assessments coupled with a renewed sensitivity towards accountability are, in my opinion, the way forward.