Italy

Francesca Ferrè; Walter Ricciardi

Economic trends

Italy's real per capita GDP has been below the European average throughout the crisis period and growth was negative in both 2009 and 2010; real per capita GDP returned to low levels of growth in 2011. Italy has run a budget deficit in every year, including the years prior to the crisis.

Health spending as a share of government expenditure has remained constant and above the European mean. Growth of per capita public and OOP expenditure on health were negative in 2010 but resumed positive growth in 2011 (Italy: Figs 1 and 2).

Italy: Fig. 1

Economic and fiscal indicators 2000–2007 and 2008–2011. Notes: Deficit/surplus: Eurostat; 10-year bond rates: European Central Bank; Other indicators: WHO Health for All.

Italy: Fig. 2

Trends in per capita spending on health, 2000–2011. Note: Spending calculated from WHO Health for All.

Policy responses

Changes to public funding for the health system

Extensive cuts to the health budget took place under the Financial Law (2011); further cuts (totalling €2.5 billion) were planned for 2012 to 2014 (2012).
The government allocated additional resources to the health sector (€1.1 million in 2010, €400 million in 2011 and €300 million in 2012) as part of an central–regional government agreement to increase funding for the NHS, long-term care and social policy and to finance investments in public sanitary infrastructure (2010).

Changes to health coverage

Population (entitlement)

No response reported.

The benefits package

Some regions reclassified drugs covered by the NHS (de-listing, price renegotiation within regional drug reference lists and setting maximum reimbursement limits when equivalent drugs become available); the main criteria for reclassification are clinical and cost–effectiveness, disease prevalence, drug's toxicity and drug's acceptance by patients) (since 2008).
Proposed adding services to the benefits package (treatment for 110 new rare diseases, chronic obstructive pulmonary disease, chronic osteomyelitis, chronic renal pathology, compulsive gambling, epidural anaesthesia) (proposed in 2012 but not yet implemented).

User charges

By 2011 the number of regions applying co-payments for outpatient prescriptions had risen to 16 (up from 12 in 2010).
User charges for outpatient specialist visits and outpatient diagnostic services (introduced for one fiscal year in 2007) abolished (2008) and later reintroduced and increased (a minimum charge of €10) (2011).
User charges increased for non-urgent treatment in emergency departments (to a minimum charge of €25), with regions free to set the actual amounts charged (2011).
Most regions applied user charges based on household income.

Changes to health service planning, purchasing and delivery

Prices of medical goods

Reduction of the value of public contracts for medical goods (excluding pharmaceuticals) by 5% and allowed contracts to be withdrawn where the price in one region is over 20% of the reference price (2012).
Medical devices budget capped at 4.8% of NHS spending (2013, lowered to 4.4% from 2014).

Salaries and motivation of health sector workers

No update or adjustment to salaries of public health care workers (2010 onwards).
In regions with financial deficits, a limit of 5–10% of total health care work is placed on new recruitment numbers (2008 onwards).
In some regions, incentives for early retirement introduced (2008 onwards).
Health care personnel expenditure (salaries etc.) for 2013–2015 cut by 1.4% (compared with 2004 levels).

Payment to providers

Introduction of more stringent quasi-market contracts with private providers in some regions (2008). For example, regions with deficits introduced more informed commissioning of private providers and budget allocations were strictly defined (see below).
Performance measurement introduced and linked to payment of providers as a cost-containment measure (2010).
Reduction of NHS spending on public services contracts by 10% compared with 2012 (2013).
Mandated public hospitals to make purchasing requests through the National Purchasing Agency for Medical Goods and Services (2012).
Expenditure on medical devices reduced leading to reductions in Ministry of Health spending:
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reduction of €22 million in 2013 (Health Ministry's budget planned for 2013 was €278 million);
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reduction of €30 million in 2014;
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reduction of €35 million projected for 2015.

Overhead costs: restructuring the Ministry of Health and purchasing agencies

No response reported.

Provider infrastructure and capital investment

The government imposed a reduction in the number of hospital beds: 3.7 beds per 1000 population (down from 4 beds per 1000), of which 0.7 are for rehabilitation and long-term care (2012). It also imposed a reduction of the hospitalization rate from 180 per 1000 inhabitants to 160, 25% of which should be in day hospitals (2012). All targets were to be achieved by 30 November 2012.

Priority setting or protocols to change access to treatments, coordination of care and patterns of use

The government sought to improve coordination of care by requesting the development of GP group practices, integration between hospital and primary care services and adoption of policies aimed at shifting patients from inpatient hospital care to day-hospital care or to community/home care (2012).

Waiting times

Introduction of a range of policies to improve timely access to services, including the introduction of priority groups and specific diagnostic–therapeutic pathways with the involvement of GPs, volume controls for outpatient care by priority group, increased capacity through agreements with NHS providers, identifying facilities with guaranteed maximum waiting times, direct purchasing of extra visits and tests from private providers by local health units, activating central booking centres, penalties for patients who do not keep appointments and making user charges payable prior to accessing care (introduced with the National Health Plan (Piano Sanitario Nazionale) 2006–2008 and further defined by National Plan for the Management of Waiting Lists (Piano Nazionale Gestione Liste d'Attesa) 2010–2012).

Health promotion and prevention

Minimum age for purchasing tobacco and alcohol raised to 18 (2012).

Bookshelf ID: NBK447856

Contents

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Bookshelf

Economic crisis, health systems and health in Europe: Country experience [Internet].