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Italy’s health-care system is a regionally organized National Health Service (Servizio Sanitario Nazionale, SSN) that provides universal coverage largely free of charge at the point of delivery. At national level, the Ministry of Health (supported by several specialized agencies) sets the fundamental principles and goals of the health system, determines the core benefit package of health services guaranteed across the country, and allocates national funds to the regions. The regions are responsible for organizing and delivering health care. At local level, geographically based local health authorities (Aziende Sanitarie Locali) deliver public health, community health services and primary care directly, and secondary and specialist care directly or through public hospitals or accredited private providers.
Patient empowerment and patient rights are not specified by a single law but are present in several pieces of legislation, starting with the Italian Constitution and the founding law of the national health system. Over the last 20 years, several tools have been introduced for public participation at all levels but no systematic strategy exists and implementation varies across the country, as does the satisfaction of citizens with the quality of health care. Over the last few years, measures have been taken to tackle excessive recourse to legal action against doctors and to prevent defensive medicine practices.
The National Health Service is largely funded through national and regional taxes, supplemented by co-payments for pharmaceuticals and outpatient care. In 2012, total health expenditure accounted for 9.2% of GDP (slightly below the EU average of 9.6%). While this reflects a process of upward convergence towards the EU average over the last couple of decades, part of this apparent increase is also due to relatively weak GDP growth for Italy over that period.
Public sources made up 78.2% of total health-care spending, with private spending, mainly in the form of out-of-pocket (OOP) payments (17.8%), accounting for the remainder – these OOP payments are mainly for diagnostic procedures (laboratory tests and imaging), pharmaceuticals, specialists visits and for unjustified (non-urgent) interventions provided in hospital emergency departments. Only about 1% of total health-care expenditure is funded by private health insurance. The production, distribution and pricing of pharmaceuticals are strictly regulated by a national agency, and provisions are made progressively more complex by repeated attempts at cost-containment of pharmaceutical expenditure.
Health care is delivered mainly by public providers, with some private or private-public entities. Although reforms in 1992 aimed to introduce a quasimarket system with patients free to choose any provider, in practice these arrangements vary across regions and, in some regions, are barely present. Only in the regions of Lazio, Campania, Molise and Lombardy is there a relatively high level of private care, with around 30% of total hospitalization supplied by private providers.
In general, doctors employed by the National Health Service are salaried and have civil servant status, although general practitioners and paediatricians are independent professionals, paid via a combination of capitation and fee-forservices for some interventions. All salaried doctors are allowed to practise privately and can earn additional income on a fee-for-service basis; they are encouraged to do so within National Health Service facilities, and then pay a proportion of their income to that facility. ( HiT )