1. Apolone, Giovanni MD
  2. Lattuada, Luca MD


Abstract: Italy, as other developed European countries, has a national health service (NHS) that, in principle, offers universal health care and coverage to Italians and other legal (non-Italian) residents who have full access to health care. Although Italy has always spent less for health care than other European countries (Italy, in 2002, spent about 8% of its gross national product for health care, which is approximately half the level of spending in the U.S.), the government's lack of control over spending remained the most relevant problem. To enhance the capability to control and monitor the system, mainly in terms of expenditures and costs, from the late 1990s to the present, new health reforms were introduced. These reforms were in the context of a wider change involving other politics and administrative aspects, with a strong push to decentralize the decisions and the accountability at the regional level. Now, each region has an individual Health Regional Fund allocated for health care, along with the subsequent need to implement regional and individualized strategies to assure the governance of the cost and quality of care. The National Department of Health now is solely responsible to control and monitor the delivery of the essential level of care at the regional level, and they have maintained the governance of the drug policy. Although the changes synthesized above will require a long period to be fully implemented, a few negative effects have already occurred. Nevertheless, all citizens in Italy will have full access to any level of care, without any restrictions, for complex and costly procedures (as no explicit selection/adverse criteria were implemented), and the current policy on drugs does not imply any barriers for people (as essential drugs are directly and fully reimbursed by the NHS, with a small copayment being the only intervention that may be occasionally implemented when considered necessary).


ITALY, AS OTHER DEVELOPED European countries, has a national health service (NHS) that in principle offers universal health care and coverage through a prepaid compulsory health insurance that is managed by the central government, which is responsible for both funding and supplying services to the population (McCarthy, 1992). Italians and other legal non-Italian residents have full access to health care. The only prerequisite is the enrollment in the national system and the choice of a general practitioner who is responsible for primary care and referrals to other levels of care (i.e., hospitals). Until a few years ago most of the medical services provided were free, or small copayments were requested at the point of use for specific procedures and prescriptions. Recently, in the context of the efforts to control the rising costs while maintaining universal coverage, the impact of copayment has increased for diagnostics and for medicines. Nevertheless, most of health care-related expenditures (75%) are covered by the NHS; for example, 71% of expenditures for drugs prescribed in the outpatient setting in 2001 was directly covered by the NHS (Ministero della Salue, 2001).


The institutional tiers of the current Italian NHS (central government, regions, and local health authorities that deliver preventive medicine as well as inpatient and outpatient hospital services) are organized in a hierarchical structure. Ongoing innovations in the institutional framework and in financial management (i.e., regionalization of most of the politics and administrative functions with direct management and governance at regional level of all the aspects of health care) are likely to change the way these tiers interact with each other, with potential implications for health inequalities, which are mostly due to socioeconomic disparities within and between regions.