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The Italian Health Care System

by Andrea Donatini, Emilia-Romagna Regional Health Authority

What is the role of government?

The Italian National Health Service (Servizio Sanitario Nazionale) is regionally based and organized at the national, regional, and local levels. Under the Italian constitution, responsibility for health care is shared by the national government and the 19 regions and 2 autonomous provinces. The central government controls the distribution of tax revenue for publicly financed health care and defines a national statutory benefits package to be offered to all residents in every region—the “essential levels of care” (livelli essenziali di assistenza). The 19 regions and two autonomous provinces have responsibility for the organization and delivery of health services through local health units. Regions enjoy significant autonomy in determining the macro structure of their health systems. Local health units are managed by a general manager appointed by the governor of the region, and deliver primary care, hospital care, outpatient specialist care, public health care, and health care related to social care.

Who is covered and how is insurance financed?

Publicly financed health care: The National Health Service covers all citizens and legal foreign residents. Coverage is automatic and universal. Since 1998, undocumented immigrants have access to urgent and essential services. Temporary visitors can receive health services by paying for the costs of treatment.

Public financing accounted for 78 percent of total health spending in 2013, with total expenditure standing at 9.1 percent of GDP (OECD, 2014). The public system is financed primarily through a corporate tax (approximately 35.6% of the overall funding in 2012) pooled nationally and allocated back to regions, typically the source region (there are large interregional gaps in the corporate tax base, leading to financing inequalities), and a fixed proportion of national value-added tax revenue (approximately 47.3% of the total in 2012) collected by the central government and redistributed to regions unable to raise sufficient resources to provide the essential levels of care (Ministero dell’Economia e delle Finanze, 2012).

Regions are allowed to generate their own additional revenue, leading to further interregional financing differences. Every year the Standing Conference on Relations between the State, Regions, and Autonomous Provinces (with the presidents of the regions and representatives from central government as its members) sets the criteria (usually population size and age demographics) to allocate funding to regions. Local health units are funded mainly through capitated budgets.

The 2008 financial law established that regions would be financed through standard rates set on the basis of actual costs in the regions considered to be the most efficient. Established in legislation, this policy is not yet operating.

Since the National Health Service does not allow members to opt out of the system and seek only private care, substitutive insurance does not exist. At the same time, complementary and supplementary private health insurance is available (see below).

Privately financed health care: Private health insurance plays a limited role in the health system, accounting for roughly 1 percent of total spending in 2009. Approximately 15 percent of the population has some form of private insurance, which generally covers services excluded under the LEA, to offer a higher standard of comfort and privacy in hospital facilities, and wider choice among public and private providers. Some private health insurance policies also cover copayments for privately provided services, or a daily rate of compensation during hospitalization (Thomson et al., 2009). Tax benefits favor complementary over supplementary voluntary insurance.

There are two types of private health insurance: corporate, where companies cover employees and sometimes their families; and noncorporate, with individuals buying insurance for themselves or for their family. Policies, either collective or individual, are supplied by for-profit and nonprofit organizations. The market is characterized by the presence of three types of nonprofit organizations: voluntary mutual insurance organizations, and corporate and collective funds organized by employers/professional categories for their employees/members.

Approximately 74 percent of policies are purchased by individuals, while the remaining 26 percent are purchased by groups.

What is covered?

Services: Primary and inpatient care are free at the point of use. Positive and negative lists are defined using criteria related to medical necessity, effectiveness, human dignity, appropriateness, and efficiency in delivery. Positive lists identify services (e.g., pharmaceuticals, inpatient care, preventive medicine, outpatient specialist care, home care, primary care) offered to all residents. Outpatient optometrist visits are covered, while corrective lenses are not. Negative lists, on the other hand, identify services not offered to patients (e.g., cosmetic surgery), services covered only on a case-by-case basis (e.g., orthodontics and laser eye surgery) and services for which hospital admissions are likely to be inappropriate (e.g., cataract surgery). Regions can choose to offer services not included in the essential levels of care but must finance them themselves.

Essential levels of care do not include a specific list of mental health, preventive, public health, or long-term care services. Rather, national legislation defines an organizational framework for mental health services, with local health authorities obliged to define the diagnostic, curative, and rehabilitative services available. Essential levels of care also outline general community and individual levels of preventive services to be covered by the National Health Service, including hygiene and public health, immunization, and early diagnosis tools. They broadly state that rehabilitative and long-term inpatient care are to be delivered as part of a standard, inpatient curative care program.

Prescription drugs are divided into three tiers according to clinical effectiveness and, in part, cost-effectiveness. The first tier is covered in all cases; the second, only in hospitals; and the third tier is not covered. For some categories of drugs, therapeutic plans are mandated, and prescriptions must follow clinical guidelines.

Dental care is included in the essential levels of care for specific populations such as children (up to 16 years old), vulnerable people (the disabled, people with HIV, those with rare diseases), people in economic need, and individuals with urgent/emergency need. For others, dental care is generally not covered and is paid for out-of-pocket.

Cost-sharing and out-of-pocket spending: Procedures and specialist visits can be prescribed either by a general practitioner (GP) or by a specialist. While there are no user charges for GP consultations and hospital admission stays, patients pay a copayment for procedures and specialist visits up to a ceiling determined by law—currently, at €36.15 (USD48) per prescription. Therefore, a patient who receives two separate prescriptions (e.g., an MRI scan and a laboratory test) after a visit pays €36.15 (USD48) for each prescription.

(Please note that throughout this profile, all figures in USD were converted from EUR at a rate of about €0.76 per USD, the purchasing power parity conversion rate for GDP in 2013 reported by OECD (2014b) for Italy.)

To address rising public debt, in July 2011 the government introduced, along with other economic initiatives, an additional €10 (USD13) copayment for each prescription. Copayments have also been applied to outpatient drugs at the regional level, and a €25 (USD33) copayment has been introduced for “inappropriate” use of emergency services (although some regions have not enforced this copayment). No other forms of deductibles exist. Public and private providers under a contractual agreement with the National Health Service are not allowed to charge above the scheduled fees.

All individuals with out-of-pocket payments over €129 (USD170) in a given year are eligible for a tax credit equal to roughly one-fifth of their spending, but there are no caps.

In 2013, 18 percent of total health spending was paid out-of-pocket, mainly for drugs not covered by the public system and for dental care (OECD, 2014). Out-of-pocket payments can be used to access specialist care and, to a lesser extent, inpatient care delivered in private and public facilities to paying patients.

Safety net: Exemptions from cost-sharing are applied to people over age 65 and under age 6 who live in households with a gross income below a nationally defined threshold (approximately €36,000 [USD47,360]); people with severe disabilities, as well as prisoners, are exempt from any cost-sharing. People with chronic or rare diseases, people who are HIV-positive, and pregnant women are exempt from cost-sharing for treatment related to their condition. Most screening services are provided free of charge.

How is the delivery system organized and financed?

Primary care: Primary care is provided by self-employed and independent physicians, general practitioners (GP) and pediatricians, under contract and paid a capitation fee based on the number of people on their list (Lo Scalzo et al., 2009). Local health units also can pay additional allowances for the delivery of planned care to specific patients (e.g., home care for chronically ill patients), for reaching performance targets (e.g., to reward effective cost containment on pharmaceuticals, laboratory tests, and therapeutic treatments prescribed), or for delivering additional treatments (e.g., medications, flu vaccinations). Capitation is adjusted for age and accounts for approximately 70 percent of the overall payment. The variable portion comprises fee- for-service payment for specific treatments, including minor surgery, home care, preventive activities, and taking care of chronically ill patients.

Payment levels, duties, and responsibilities of GPs are determined in a collective agreement signed every three years by consultation between central government and the GPs’ trade unions. In addition regions and local health units can sign contracts covering additional services.

In 2011, there were approximately 53,800 GPs and pediatricians (33.5%) and 106,800 hospital clinicians (66.5%) (Ministero della Salute, 2014). Patients are required to register with a gatekeeping GP, who has incentives to prescribe and refer only as appropriate: in most cases incentives are awarded only to those GPs and pediatricians who achieve a predetermined spending or consumption target (e.g., per capita spending on drugs or diagnostic imaging). People may choose any physician whose list has not reached the maximum number of patients allowed (1,500 for GPs and 800 for pediatricians) and may switch at any time.

In recent years the solo practice model has been progressively modified toward group practice, particularly in the northern part of the country. Legislation encourages GPs and pediatricians to work in three ways: base group practice, where GPs from different offices share clinical experiences, develop guidelines, and participate in workshops that assess performance; network group practice, which functions like base group practice but allows GPs/pediatricians to access the same patient electronic health record system; and advanced group practice, where GPs/pediatricians share the same office and patient health record system, and are able to provide care to patients beyond individual catchment areas. In 2010, approximately 67 percent of GPs and 60 percent of pediatricians were working in a team (Ministero della Salute, 2014). Group practices typically range from three to eight GPs.

General practitioners working in base group practices receive an additional €2.58 (USD3.4) per patient, while GPs in a network practice receive €4.7 (USD6.2) (the payment for pediatricians is €8 [USD11]). Lastly, GPs working in a group practice receive €7 (USD9) (€9 [USD12] for pediatricians). General practitioners or pediatricians employing a nurse or secretary receive an additional payment of €4 (USD5.3) for nurses and €3.5 (USD4.6) for a secretary.

Some regions are promoting care coordination by asking their GPs to work in groups involving specialists, nurses, and social workers. The aim is for each group to be in charge of all the health needs of its assigned population. This is encouraged by additional payments to GPs (e.g., paying each GP €1.3 (USD1.7) per patient in Emilia-Romagna) and supplying teams with personnel, in most cases nurses and social workers.

Outpatient specialist care: Outpatient specialist care is generally provided by local health units or by public and private accredited hospitals under contract with them. Once referred, patients are given choice of any public or private accredited hospital, but are not allowed to choose a specific specialist. Outpatient specialist visits are generally provided by self-employed specialists working under contract with the National Health Service. They are paid an hourly fee contracted nationally between the government and the trade unions; the current rate is approximately €32 (USD42). Outpatient specialists can see private patients without any limitations, whereas specialists employed by local health units and public hospitals cannot. Multispecialty groups are more common in northern regions of the country.

Administrative mechanisms for paying primary care doctors and specialists: Patient copayment is limited to outpatient specialist visits and diagnostic testing, while primary care visits are provided free of charge. Copayments are usually paid by the patient before receiving the visit/test.

After-hours care: After-hours centers are generally located in local health unit–owned premises and staffed only by doctors employed on an hourly basis by the local health unit. The hourly rate, negotiated between the GP trade unions and government, is approximately equal to €25 (USD33). Following examination and initial treatment, the doctor can prescribe medications, issue employees’ medical certificates, and recommend hospital admission. Guardia medica is a free telephone health service for emergency cases. It normally operates at night and on weekends, and the doctor on duty usually provides advice, in addition to home visits if needed.

Information on a patient’s visit is not routinely sent to the patient’s GP. To improve accessibility, government and GP associations are trying to promote a model where GPs, specialists, and nurses coordinate to ensure 24-hour access and avoid unnecessary use of hospital emergency departments. Implementation is uneven across regions.

Hospitals: Depending on the region, public funds are allocated by local health units to public and accredited private hospitals. In 2011 there were approximately 194,000 beds in public hospitals and 47,500 in private accredited hospitals (Ministero della Salute, 2014). Public hospitals either are managed directly by the local health units or operate as semi-independent public enterprises. A diagnosis-related group-based prospective payment system operates across the country and accounts for most hospital revenue but is generally not applied to hospitals run directly by local health units, where global budgets are common. Rates include all hospital costs, including those of physicians. Teaching hospitals receive additional payments (typically 8% to 10% of overall revenue) to cover extra costs related to teaching. There are considerable interregional variations in the prospective payment system, such as how the fees are set, which services are excluded, and what tools are employed to influence patterns of care. However, all regions have mechanisms for cutting fees once a spending threshold is reached, to contain costs and incentives to increase admissions.

In all regions, a portion of funding is administered outside the prospective payment system (e.g., funding of specific functions such as emergency departments and teaching programs).

Hospital-based physicians are salaried employees. Public hospital physicians are prohibited from treating patients in private hospitals; all public physicians who see private patients in public hospitals pay a portion of their extra income to the hospital.

Mental health care: Mental health care is provided by the National Health Service in a variety of community- based, publicly funded settings, including community mental health centers, community psychiatric diagnostic centers, general hospital inpatient wards, and residential and semiresidential facilities. In 2010 there were 1,737 residential facilities and 784 semiresidential facilities providing care to approximately 60,000 patients. Promotion and coordination of mental illness prevention, care, and rehabilitation are the responsibility of specific mental health departments in local health units. These are based on a multidisciplinary team, including psychiatrists, psychologists, nurses, social workers, educators, occupational therapists, people with training in psychosocial rehabilitation, and secretarial staff. In most cases primary care does not play a role in provision of mental health care; a few regions have experimented with assigning the responsibility of low-complexity cases (mild depression) to general practitioners (Lo Scalzo et al., 2009).

Long-term care and social supports: Patients are generally treated in residential (approximately 221,000 beds in 2011) or semiresidential (50,000 beds) facilities, or in community home care (approximately 606,000 cases). Residential and semiresidential services provide nurses, physicians, specialist care, rehabilitation services, medical therapies, and devices. Patients must be referred in order to receive residential care. Cost-sharing for residential services varies widely according to region, but is generally determined by patient income. Community home care is funded publicly, whereas residential facilities are managed by a mixture of public and private, for-profit and nonprofit organizations. Community home care is not designed to provide physical or mental care services but to provide additional assistance during a treatment or therapy. In spite of government provision of residential and home care services, long-term care in Italy has traditionally been characterized by a low degree of public financing and provision as compared with other European countries.

Financial assistance for patients can take two forms:

  • Accompanying allowance: Awarded by the National Pension Institute to all Italian citizens who need continuous assistance. The allowance, which is related to need but not to income or age, amounts to approximately €500 (USD658) per month.
  • Care voucher: Awarded by municipalities on the basis of income, need, and clinical severity only to residents of those municipalities offering the service. The amount ranges between €300 and €600 (USD395 to USD789) per month.

Voluntary organizations still play a crucial role in the delivery of palliative care. A national policy on palliative care has been in place since the end of the 1990s and has contributed to an increase in services such as hospices, day care centers, and palliative care units within hospitals. In 2011 there were 158 hospices, with approximately 1,700 beds. But much still needs to be done to ensure the diffusion of palliative care services and disparities persist: northern regions cared, on average, for 51 patients per 100,000 residents, while in central and southern regions the rate fell to 25 patients.

What are the key entities for health system governance?

The Ministry of Health is currently structured into 12 directorates that oversee specific areas of health care (health care planning; essential levels of care and health system ethics; human resources and health professionals; information systems; pharmaceuticals and medical devices) or supervise the main institutions related to the Ministry of Health (e.g., National Health Council, National Institute of Health).

Key nongovernmental entities supporting the Ministry of Health include the National Health Council (which provides support for national health planning, hygiene and public health, pharmacology and pharmaco-epidemiology, continuing medical education for health care professionals, and information systems) and the National Institute of Public Health (which provides recommendations and control in the area of public health).

The National Committee for Medical Devices develops cost-benefit analyses and determines reference prices for medical devices. The Agency for Regional Health Services is the sole institution responsible for conducting comparative effectiveness analysis and is accountable to the regions and the Ministry of Health.

The National Pharmaceutical Agency is responsible for all matters related to the pharmaceutical industry, including prescription drug pricing and reimbursement policies. It is accountable to the Ministry of Health and the Ministry of Economy and Finance (Lo Scalzo et al., 2009).

Payment rates for hospital and outpatient specialist care are determined by each region, with national rates (determined by the Ministry of Health) as a reference.

Some regional governments have established agencies to evaluate and monitor health care quality and to provide comparative effectiveness assessments and scientific support to regional health departments (see below). Regional governments periodically sign with the national government “Pacts for Health” linking additional resources to the achievement of health care planning and expenditure goals (see below).

Safeguarding of patients’ rights has not been uniform and has depended on the level of effort of individual regions. Regions have implemented different models of empowerment: some through standing committees, which include members from citizens’ associations, as an institutional means of patient involvement, while others have emphasized systematic patient satisfaction surveys.

Each public institution has an office for public relations (Ufficio Relazioni con il Pubblico) providing information to citizens and, in many cases, monitoring quality of services from the citizen’s point of view.

What are the major strategies to ensure quality of care?

National and regional governments, responsible for upholding quality, ensure that services included in the essential levels of care are provided and waiting times are monitored. Several regions have introduced programs for prioritizing delivery of care on the basis of clinical appropriateness of services prescribed and patient severity (France et al., 2005). All doctors under contract with the National Health Service must be certified, and all National Health Service staff participate in compulsory continuing education. The National Commission for Accreditation and Quality of Care is responsible for outlining the criteria used to select providers and for evaluating regional accreditation models (including private hospitals), which vary considerably across the system. These models do not usually include periodic reaccreditation.

Legislation passed during the 1990s covers three main components of quality: input (quality of infrastructure and human resources); process (appropriateness and timeliness of interventions); and outcome (health status and patient satisfaction) (Lo Scalzo et al., 2009).

National legislation requires all public health care providers to issue a “health service chart” with information on service performance, quality indicators, waiting times, quality assurance strategies, and the process for patient complaints. These charts also have been adopted by the private sector for its accreditation process, and must be published annually, although dissemination methods are decided regionally. Most providers issue data through leaflets and the Internet, while nurses and other medical staff are offered financial performance incentives (linked to manager evaluations but not to publicly reported data).

The National Plan for Clinical Guidelines (Piano Nazionale Linee Guida) has been implemented in recent years and has produced guidelines on topics ranging from cardiology to cancer prevention and from appropriate use of antibiotics to cesarean delivery.

Some regions have introduced disease management programs, are experimenting with chronic care models (refer to the section on coordination) and maintain registries, mainly for cancer patients and diabetes. No national registries exist. Patient surveys are not used for quality control.

What is being done to reduce disparities?

Interregional inequity is a long-standing concern. The less affluent south trails the north in number of beds and availability of advanced medical equipment, has more private facilities, and less-developed community care services. Data show a rise in interregional mobility in the 1990s, with movement particularly from southern to central and northern regions (France, 1997) and an increasing gap between the north and south (Toth, 2014).

Income-related disparities in self-reported health status are significant, though similar to those in the Netherlands, Germany, and other European countries (Van Doorslaer and Koolman, 2004).

The National Health Plan for 2006–2008 cites overcoming large regional discrepancies in care quality as key objective for reform. Directing EU resources toward health services in eight regions in the south was a first step in 2007 in reducing this persistent variation. Regions receive a proportion of funding from an equalization fund (the National Solidarity Fund), which aims to reduce inequalities. Aggregate funding for the regions is set by the Ministry of the Economy and Finance, and the resource allocation mechanism is based on capitation adjusted for demographic characteristics and use of health services by age and sex.

What is being done to promote delivery system integration and care coordination?

Integration of health and social care services has recently improved, with a significant shift of long-term care from institutions to the communities, with an emphasis on home care. Community home care establishes a home care network that integrates the competencies of nurses, GPs, and specialist physicians with the needs and involvement of the family. General practitioners oversee the home care network, liaise with social workers and other sectors of care, and take responsibility for patient outcomes.

Regions have chronic patient management programs, dealing mainly with high-prevalence conditions such as diabetes, congestive heart failure, and respiratory conditions. All programs involve different competencies although the degree of evolution is varied across regions. Some regions are also trying to set up disease management programs based on the chronic care model.

The most recent Pact for Health, signed in July 2014, is a significant step toward care integration (see below): all regions must establish “primary care complex units” (Unità Complesse di Cure Primarie) involving GPs, specialists, nurses, and social workers.

Given that, traditionally, Italian GPs work in solo practice, shifting to this new organizational arrangement will require considerable effort. To further promote integration and adoption of multidisciplinary teams, medical homes are being encouraged in some regions. (Tuscany and Emilia-Romagna have invested considerable resources in activating and promoting medical homes. In Emilia-Romagna, for example, there are currently 62 medical homes providing multispecialty care to approximately 1 million people.)

What is the status of electronic health records?

The New Health Information System has been implemented incrementally since 2002 to establish a universal system of electronic records connecting every level of care. It provides information on the services, resource use, and costs, but does not cover all areas of health care; in particular, primary care is not covered, while hospital, emergency, outpatient specialist, residential and palliative care, and pharmaceuticals are. It currently contains administrative information on care delivered, as medical information appears more difficult to gather. No unique patient identifier exists at the national level.

A core component of the New Health Information System is the nationwide clinical coding program known as “bricks,” one of the most mature elements of Italy’s developing electronic health program. It aims at defining a common language to classify and codify concepts; at sharing methodologies for measuring quality, efficiency, and appropriateness of care; and at allowing an efficient exchange of information between the national level and regional authorities.

Some regions have developed computerized networks to facilitate communication between physicians, pediatricians, hospitals, and territorial services and to improve continuity of care. These networks allow automatic transfer of patient registers, services provided, prescriptions for specialist visits and diagnostics, and laboratory and radiology test outcomes. A few regions also have developed a personal electronic health record, accessible by patients, that contains all patient medical information, such as outpatient specialty care results, medical prescriptions, and hospital discharge instructions. Personal electronic health records should provide support to patients and clinicians across the whole process of care but diffusion is still limited.

There is also a slow movement from paper to electronic prescriptions. By the end of 2014, 80 percent of all prescriptions (drugs and specialist care) were to be issued electronically, but only five regions declared that they were able to reach the goal on time.

How are costs contained?

Containing health costs is a core concern of central government, as Italy’s public debt is among the highest in industrialized nations. Fiscal capacity varies greatly across regions. To meet cost containment objectives, the central government can impose recovery plans on regions with health care expenditure deficits. These identify tools and measures needed to achieve economic balance: revision of hospital and diagnostic fees, reduction of the number of beds, increased copayments for pharmaceuticals, and reduction of human resources through limited turnover.

The Agency for Regional Health Services, in collaboration with the Ministry of Health, has authority to conduct health technology assessments and implement its findings at the regional level, but these are not yet formalized or undertaken systematically. Few regional health technology assessment agencies currently exist, and their primary function is to evaluate individual technologies. Assessments are not mandatory for new or referred procedures and devices. However, reference prices for medical devices and pharmaceuticals are set according to cost-effectiveness studies carried out by the National Committee for Medical Devices and the National Drugs Agency. Furthermore, the National Pharmaceutical Formulary bases coverage decisions in part on clinical effectiveness and cost-effectiveness. Prices for reimbursable drugs are set in negotiations between government and the manufacturer according to the following criteria: cost-effectiveness where no effective alternative therapies exist; comparison of prices of alternative therapies for the same condition; costs per day compared with those of products of the same effectiveness; financial impact on the health system; estimated market share of the new drug; and average prices and consumption data from other European countries. Prices for nonreimbursable drugs are set by the market.

What major innovations and reforms have been introduced?

Because of the regionalization of the health system, most innovations in the delivery of care take place at the regional rather than the national level, with some regions viewed as leaders in innovation. Significant innovations can be found in:

  • Pharmaceuticals: Both the National Drugs Agency and the regions are particularly active in coordinating guidelines and rules to promote appropriate and cost-effective prescribing.
  • Hospital care: Various innovations have been introduced concerning the overall organization, management of operations (e.g., planning of surgical theaters and delivery of drugs), and health information technology (e.g., electronic medical records, automation of administrative and clinical activities).

In August 2012 the parliament passed a law aimed at curbing and rationalizing public expenditure (the so-called spending review). The law promoted the prescription of generic drugs, cut the hospital bed ratio from 4 per 1,000 people to 3.7, and reduced public financing of the National Health Service by between €900M (USD1.2B) and €2.1B (USD2.8B) annually between 2012 and 2015. Many of the requirements of the law are still in the process of being implemented and effects have not yet been evaluated.

In 2012, the government approved a decree (named after Renato Balduzzi, who was health minister at that time) to reorganize health care at the regional level, with the introduction of teams of primary health care professionals to ensure 24-hour coverage; to update health care fees; to restructure governance of hospitals and local health units; to revise the list of reimbursable pharmaceuticals; and to introduce health technology assessment as a tool for renegotiating the price of less effective medicines. Evaluations of the impact of both laws are not yet available as their implementation is still under way.

The July 2014 Pact for Health defines funding (between €109B [USD143.4B] and €115B [USD151.3B] annually) for the years 2014 to 2016. In return, regions make explicit commitments to:

  • Reduce hospitalizations through appropriate use of hospitals, with progress toward home care and the creation of community hospitals offering subacute care.
  • Reorganize primary care: All regions will have to establish primary care complex units (Unità Complesse di Cure Primarie) (as described in the section on care integration) to replace all other forms of general practice networks (base group practice, network group practice, and advanced group practice).
  • Revise hospital and specialist care fees in line with health inflation and with the underlying structure of health care costs.
  • Revise copayments for outpatient specialist care to promote more equitable access.
  • Copayments currently represent a barrier for disadvantaged sectors of the population.
  • Strengthen the electronic records system.


The author would like to acknowledge Sarah Jane Reed, and David Squires as contributing authors to earlier versions of this profile.


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