Country and population

Italy is a country located in south-central Europe on a territory of 301 338 km² with a population of 56.99 million inhabitants (according to the last population census of 2001). With an estimated population of 60 million, Italy is the sixth most populous country in Europe and the twenty-third most populous in the world.

The country is subdivided into 21 regions. Four of these regions have a special autonomous status that enables them to enact legislation on some of their local matters. The country is further divided into 110 provinces and 8100 municipalities.

The population density of 202/km² is the fifth highest in the EU. The highest density is in northern Italy, as one-third of the country contains almost half of the total population. The natural growth balance per 1000 residents is among the lowest in Europe (years 2006–2009): – 0.3 balanced by the high rate of migrants entering in the country, so that the total growth rate results positive in 2009: + 5.7 (ISTAT, 2010).

Currently, the percentage of Italian people aged 0–14 years (14%) is lower than that of people aged over 65 (20%), and it is estimated that this trend will persist (ISTAT, 2010).

Development and economy

Italy is a democratic republic and member of the EU. It is also a member of major multilateral economic organizations such as the Group of Eight Industrialized Countries (G8), OECD, the World Trade Organization and the IMF. According to the OECD, in 2004 Italy’s economy was the sixth largest among industrial powers. The GDP per capita was PPP$ 30 558.391 in 2008 (IMF, 2010). Between 1980 and 2007 Italy’s Human Development Index has risen by 0.39% annually from 0.857 to 0.951 today which gives the country a rank of 18th out of 182 countries with data from 2007 (UNDP, 2009).

The unemployment rate was 8.2% in 2010 (Eurostat, 2010). Concerning education, 32.21 % of the population has finished its secondary level of education (ISTAT, 2010).

Population’s health

Various indicators show that the health of the Italian population has been improving over the last few decades. Average life expectancy reached 78.71 years for men and 84.22 years for women in 2007 while the healthy life expectancy at age 65 was 7.9 and 7.2 years respectively in the same year (Eurostat, 2010). However, in almost all demographic and health indicators, there are marked regional differences for both men and women, reflecting the economic imbalance between the north and south of the country.

The main diseases affecting the population are circulatory diseases, malignant tumours and respiratory diseases, while smoking and rising obesity levels, particularly among young people, are growing important public health challenges.

The five leading causes of death in Italy, considered as mortality rates per 10 000 after the first year of age, standardized for region and cause of death were, for men, coronary heart disease, stroke, cerebrovascular diseases, accounting for 41.11%, followed by cancers (37.84%), respiratory diseases (9.15%), accidents (5.60%) and digestive diseases (4.59%). These percentages vary slightly for women: coronary heart disease, stroke, cerebrovascular diseases (28.86%), cancers (20.12%), respiratory diseases (3.73%), digestive diseases (2.89%), accidents (2.41%) (ISTAT, 2007a).

In 2007, the infant mortality rate was 3.3/1000 and the neonatal mortality rate was 2.4/1000 (ISTAT, 2009; WHO Regional Office for Europe, 2010). Total fecundity rate (average number of children per woman) was 1.37 in 2007 (Osservatorio Nazionale sulla salute nelle regioni Italiane, 2009b).

Characteristics of the health care system

Health care in Italy is a constitutional right accorded to all Italian citizens. All Italians are enrolled in the National Health System (NHS) – founded in 1978 – from birth and have the right to select a paediatrician or GP according to their place of residence. Starting from the 1999 reform, health care in Italy has become a regionally based National Health Service which still provides universal coverage free of charge at the point of service. The national level is responsible for ensuring the general objectives and fundamental principles of the national health care system (including the National Agreement for primary care services). Regional governments, through the regional health departments, are responsible for ensuring the delivery of a benefits package through a network of public population-based health care organizations (local health authorities), public hospital trusts and accredited private providers (Ministero della Salute, 1992, 2006, 2009a, 2010a).

Total expenditure on health as a proportion of GDP has risen from 7.3% in 1995 to 9.5% in 2009 (see Table A15.1). Public spending on health accounted for 77.0% of the total in 2007, but over the years there has been considerable fluctuation, due to GDP rates and co-payment policies implemented by different governments. This has affected the private share of health care spending (WHO Regional Office for Europe, 2010a), without considering the out-of-pocket payments.

Table A15.1

Development of health care resources and utilization.

Compared to EU averages, Italy through time has become characterized by a decreasing use of hospitals (in terms of hospital beds, length of stay and admissions), still probably not balanced by a proper professional case-mix to manage chronic conditions (as there is still a higher number of physicians with a simultaneous lower incidence of GPs and a lower number of nurses).

2.1. Primary care governance

Since 1978 the role of primary care services has been strictly associated with the local provision of universal, equitable and accessible care in line with the original constitutional right. However, as health care needs evolved through time, the original framework for primary care began to be too rigid and had a limited portfolio of services. From the end of 1990s, primary care has become central for the effectiveness of care and the sustainability of the NHS, which led to evolution of the national working agreements, active involvement of regions in defining their own primary care settings accompanied by some resistance to change from professionals (worried about losing privileges of capitation combined with gatekeeping) (Ministero della Salute, 1992, 2006, 2009a, 2010a).

The years 2007–2009 have seen an increasing debate, with different propositions for the future of primary care in Italy coming from successive national governments of different political colours, from the more advanced regions and also from a coalition of major GPs’ trade unions (e.g. FIMMG – Italian Federation of General Practitioners, SNAMI – Italian National Syndicate of Independent Doctors, etc.) and scientific associations (e.g. SIMG – Italian Society of General Practice etc.).

The priority given by public authorities to achieve integration of GPs’ developing networks, associations and other forms of grouping, including with other health care professionals, was indeed in Italy a “slow, creative but moving process”, observable since the National Agreement of 2005 between the government and GPs’ trade unions. These forms of inter-professional collaboration, initially involving mainly GPs, have been enhanced through supplementary incentives delivered to physicians until the National Agreement of 2009 (where, for the first time, it is stated that “the participation of GPs in any existing form of group practice becomes compulsory”).

The aim is to create new organizational models based on the integration of different professionals (e.g. GPs, paediatricians, out-of-hours physicians, nurses, specialists working in outpatient facilities, social workers, administrative personnel, etc.) working together to improve accessibility, equity and continuity of care for patients. According to this vision, different models are currently activated in many regions, such as primary care units in Emilia Romagna region, territorial units of primary care in Veneto region and health houses in Toscana region.

As a last step of this national policy oriented towards full implementation of multidisciplinary practices, the Agreement of 2010 has introduced the concept of “primary care complex units” conceived as an additional evolution of existing models of multi-professional practice, with a strong emphasis on continuity of care, chronic disease management and integration with social services. The challenge is to reshape Italian primary care according to the Chronic Care Model, moving from “reactive” medicine to “proactive” medicine.

Since 2005 the reorganization of primary care services is also a priority within the so-called “health deals” between government and regions, which allocate the distribution of national resources for health care among the 21 regions according to the provision of “essential levels of care” (among which primary care is included): in this perspective, the decentralization of responsibilities for primary care has basically followed the reforming process of the entire NHS (Coalition of Trade Unions and Scientific Associations, 2007; Ministero della Salute, 2009b, 2009c, 2010b).

The National Agreement, signed after negotiations between a central agency delegated by the government (called SISAC) and the main trade unions of GPs, defines the criteria for the distribution of primary care professionals on a territorial basis (basically, the number of doctors being decided according to the distribution of the population in so-called “territorial scopes” within each region). Exceptions can be made for areas that are not covered or disadvantaged areas according to national or regional regulation.

The Agreement fixes a maximum number of patients each GP or paediatrician can have on their list: full-time GPs and paediatricians can have respectively up to 1500 and 800 patients. Only one GP can be assigned to a territorial scope of 1000 residents (or a fraction of 1000 population above 500, deducting individuals between 0 and 14 years of age – who are assigned to paediatricians – as of 31 December 2010). Regions, however, can set up for their own territorial scopes a different ratio between GPs and a resident population, with a variation to be agreed in regional integrative agreements and up to a maximum increase of 30% compared to national contracts (Ministero della Salute, 2009a).

In 2000, a further measure introduced principles of fiscal federalism leading to a progressive full responsibility of regions for health care expenditure (including solidarity mechanisms among regions and additional regional taxes to face deficits). In this scenario the evolution of primary care services has been shaped according to local political wisdom, the managerial capabilities of regional health departments and regional overall financial performance (Italian Parliament, 2000).

Since 2005 the National Agreement for primary care defines standards and objectives for professionals (mainly rewarded through capitation), delegating to regions the negotiation of additional objectives and incentives (mainly delivered according to organizational standards and pay-for-performance). Following this logic, the National Agreement tends to reflect national priorities (e.g. professional standards, immunization campaigns, evidence-based guidelines and other priorities according to national health plans or health deals between government and regions), while most regions do decide on additional priorities and organizational aspects of service provision (e.g. chronic disease management programmes, home care services, primary care delivery models). In this perspective variability in priority-setting and provision of care is increasing across Italian regions.

2.2. Economic conditions of primary care

The extension of universal health care coverage to the whole population is a key characteristic of the Italian health care system. Universal coverage entitles all citizens, regardless of their social status, to equal access to essential health care services that are necessary and appropriate to promoting, maintaining and restoring health in the population according to the principle of universalism.

Essential health services are provided free of charge or at a minimal charge, and include general medical and paediatric services; essential drugs (including for chronic diseases); treatments administered during hospitalization; rehabilitation and long-term post-acute inpatient care; instruments and laboratory diagnostics; as well as other specialized services for early diagnosis and prevention.

In 2008 the total public health care expenditure reached €106.5 billion (equal to 6.8% of GDP – adding private expenditure it reaches 9.1% of GDP); primary care direct costs accounted for €6.08 billion (5.7% of total expenditure, considering only payments to GPs, paediatricians, out-of-hours physicians and specialists working in community health care centres). Just as an additional comparator, pharmaceutical expenses prescribed by primary care professionals accounted for €11.2 billion – 10.5% of the total (OECD, 2009).

Until 1978, GPs and paediatricians were paid a fee-for-service by the patients’ mutual fund. Since 1978, both GPs and paediatricians can choose to work full – or part-time for the NHS, with local health authorities paying them on a capitation basis. GPs and paediatricians are self-employed physicians working for the NHS through a national agreement which pays them mostly on a capitation basis according to the number of people (adults or children) registered on their list. Professionals can practise privately within regulated limits, above which their remuneration is downsized proportionally to the volume of private activity. Out-of-hours physicians and outpatient specialists working in community health care are directly contracted by local health authorities and remunerated by hourly fees according to the volume of activity.

For instance, out-of-hours physicians or physicians for continuity of care (a service available daily from 8 p.m. to 8 a.m. and 24 hours during weekends – when GPs and paediatricians do not work) are a particular category of medical staff, as they are not required to be specialists or GPs (just physicians). Even GPs whose lists do not exceed an established number of patients can apply to be assigned to such a service by the local health authority alongside their activities in regular practice (especially during the tourist season or in disadvantaged areas).

The remuneration of GPs and paediatricians is modulated by national agreements between the central government and trade unions and consists of a fixed amount based on capitation (70% of income), a variable amount based on fees for services (e.g. minor surgery in an ambulatory setting, preventive activities, immunizations) and an additional part in the form of a pay-for-performance mechanism or other financial incentives. The fixed and the variable amounts are determined at national level, while each region and each local health authority can decide whether and how to provide the additional part. Financial incentives are increasing in terms of relevance for GPs’ income: incentives have been devised, for instance, to provide the ambulatory setting with nursing and administrative staff, and an information system, to enrol patients in disease management programmes or to improve physicians’ adherence to clinical guidelines. So far, these incentives have been linked to process and output results and not to clinical outcomes.

The National Agreement signed in 2009 introduced a fixed per capita payment equal to €40.05. Each GP receives an additional per capita payment based on the number of patients and on the years elapsed since graduation. The rate is currently between €1.91 for paediatricians with over 1400 patients and recent graduation and €18.46 for GPs with a small number of patients (less than 500) and over 27 years since graduation. Therefore, a GP with both an average number of 1000 patients and years of practice earns a fixed annual gross income of about €50 000. In addition, physicians who set up a group practice, inter-professional collaborations or organizational models receive additional per capita payments, with additional payments for protecting physicians against risks and for physicians working exclusively within the NHS. Fig. A15.1 shows that the income of an average GP is lower compared to the income of paediatricians, lower than that of some medical specialists, and higher than the income of paramedical professionals and nurses.

Fig. A15.1

How does the average income of mid-career health professionals relate to that of a mid-career GP.

Historical expenditure, demographic characteristics and epidemiological indicators are proposed as variables to estimate the expected expenditure. The same payment structure applies to paediatricians, but per capita payments are higher than those of GPs: the National Agreement signed in 2009 introduced a fixed per capita payment equal to €83.65. Each paediatrician then receives an additional per capita payment based on the number of patients and the years elapsed since graduation. The rate is currently between €4.14 for physicians with 700 patients and recent graduation, and €37.96 for GPs with fewer patients (less than 250) and over 22 years since graduation (SISAC, 2010).

2.3. Primary care workforce development

Physicians have to graduate from a medical faculty in a public or private university. The undergraduate programme lasts six years, during or after which students must work within a hospital ward attending internships. After university, medical school graduates must take a state examination to be put on a register and be allowed to practise as physicians. They can then choose among various professional paths depending on the kind of postgraduate specialization programme attended. GPs and hospital physicians have to follow two different career paths: most medical students consider specializations based on hospitals as “a first best”, whereas the limitation of such places, the recognition of new specializations in general practice and the progressive feminization of the professional supply chain have recently increased the attractiveness of the general practice profession. Primary care physicians are authorized to work in the NHS after successfully completing a three-year specialization course in general medicine and acquiring clinical experience as temporary staff in NHS facilities. Regional health departments, under the supervision of the Ministry of Health, are in charge of coordinating courses and training for those specializing as GPs. GPs and paediatricians initially assess the patient and are expected to provide most primary care. They act as gatekeepers for access to secondary services, write pharmaceutical prescriptions and visit patients at home if necessary, as well as vaccinate patients against influenza during the vaccination campaign period. Moreover, in accordance with Legislative Decrees No. 256/1991 and 368/1999, certificates issued by other EU Member States to practise as a GP are equivalent to those issued in Italy and therefore are valid for practice in Italy (European Council, 1986). Fig. A15.2 shows the decline in supply of GPs over a five-year period. The majority of GPs are older than 50 years of age (Faber, Voerman & Grol, 2009).

Fig. A15.2

The development in supply of primary care professionals per 100 000 inhabitants in the most recent available five-year period. Source: Eurostat, 2010

Future hospital doctors and specialists attend courses lasting from four to six years – depending on their clinical specialization – at a medical specialist school at university. Physicians have to take an exam to be admitted to the chosen specialist schools, since a numerus clausus is in place in each university hospital (and not at national level as in other European countries). Residents can benefit from a scholarship while attending their school. After specialization, their training will continue under the rules provided by the national continuing education in medicine programme, which was launched in 2000. All health professionals working in private or public facilities are required to undergo continuing education training programmes based on a learning credit-system.

In 1992 and 1994, major reforms in the nurses’ training programmes were introduced, which led to the closure of the old regional nursing – three-year – courses which enrolled students only after two years of high school. The main aim of legislation for the nursing profession over the last decade has been to provide nurses with a more autonomous and active role and to give them new responsibilities so that this important profession is no longer seen as an auxiliary one. Under the current arrangements, those wishing to be registered as qualified nurses are required to complete a three-year university degree and to take a state examination. Nurses can attend postgraduate programmes in paediatrics, geriatrics, psychiatry, problematic areas and public health care. Complementary training courses are also aimed at training managers and teachers in nursing. In 2000, the role of nurse management was established, with a degree in the nursing sciences for training managers and teachers in nursing. In 2004–2005, a postgraduate two-year nursing specialist degree, which is only available to nurses with a three-year degree, began taking enrolments.

3.1. Access to primary care services

All GPs are independent contracted professionals working within catchment areas named districts (60 000 inhabitants on average) that operate under the control of local health authorities and provide primary care, non-hospital based specialty medicine and residential care to the population living in the area in line with the “essential levels of care” established at national level. GPs are the first contact for the most common health problems and, as already pointed out act, as gatekeepers for other services. The availability of GPs (per 100 000 inhabitants) ranges from 89 GPs in Lazio to 52 GPs in the Autonomous Province of Bolzano. Shortages of GPs exist in some regions.

In 2007, each GP averaged 1094 patients. The regional range of average patient population ranged from 977 (Lazio) to 1605 patients (Provincia Autonoma di Bolzano). Each paediatrician averaged 1010 children, ranging from 855 in Sardegna to 1508 children in Provincia Autonoma di Bolzano (ISTAT, 2007b).

People may choose any GPs or paediatrician they prefer at any time, provided that the physician’s list has not reached the maximum number of patients allowed. Patients have free access to their GPs, according to opening hours, and do not have to pay for visits or prescriptions. Co-payments exist for certain drugs or specialist visits when these are prescribed by the physician. When patients choose to go directly to specialists they pay out of pocket.

General practices must be open for five days a week, preferably from Mondays to Fridays, with at least two opening times in afternoons or mornings and anyhow on Mondays. The number of hours is regulated according to the size of the patient list (a minimum of 5 hours per week to be guaranteed for lists of up to 500 patients, 10 hours per week for 500 to 1000 patients, and 15 hours per week for 1000 to 1500 patients). For group practices one afternoon session has to last till 7.00 p.m. Patients can receive primary care services during nights, weekends and public holidays from professionals other than their regular GP or paediatrician, the so-called out-of-hours physicians – as described in section 2.2 – usually working in different premises (such as independent ambulatories of local health authorities).

Organizational arrangements vary across regions; besides direct access, telephone consultations are still predominant while other measures are variably used (see Fig. A15.3).

Fig. A15.3

The extent to which organizational arrangements commonly exist in primary care practices or primary care centres. Source: Dobrev et al., 2008.

Exemptions to any co-payment exist (specialist consultations, diagnostics and rehabilitation services) for patients with oncological problems, chronic diseases, rare diseases and disabilities. Currently 56 conditions, 284 diseases and 47 groups of rare diseases are exempted (Ministero della Salute, 2001). Exemptions for drug co-payments are managed regionally. Also citizens with a family income below a certain level, with children below the age of 6 or adults above the age of 65, and those who are unemployed or receiving a minimum pension are exempted.

Specialist outpatient services, including visits and diagnostic and curative activities, are provided either by local health authorities or by accredited public and private hospitals. Services are listed in specific formularies that vary among regions. People are allowed to access specialist care in two ways:

• indirect access (referral): after approval by their GP, people are free to choose their provider among those accredited by the NHS (with no cost besides limited co-payments);
• direct access: patients can obtain an appointment through telephone central booking systems for the following health services: gynaecology, dental care, paediatrics (for those who have decided not to register their children with a designated paediatrician), optometric services and psychiatric services for children. In emergency cases, direct access is allowed for all health services. Urgency is established directly by the doctor. Visits to a specialist and medical devices incur user charges.

Since waiting lists can be very long and the quality of services is not always satisfactory, especially in central and southern regions, many people seek care in private clinics, particularly if they have voluntary health insurance (paid out of pocket, or provided by some employers) covering the associated costs. Moreover, 8% of people seek care outside their own region, mainly going from the south to the north of Italy.

In terms of available data, the latest report published in 2005 shows the number of outpatient visits in terms of laboratory tests, diagnostic procedures and other ambulatory services per 1000 inhabitants (Ministero della Salute, 2010d). For each category, a national parameter has been established as a benchmark. For laboratory tests, Veneto, Lombardy and Tuscany have definitively higher levels of usage than the benchmark (that is 13 510 tests per 1000 inhabitants), while the autonomous provinces of Trento and Bolzano, and the regions of Abruzzo and Molise have somewhat lower values.

Concerning access to integrated home care for terminally ill patients, and hospices, it is necessary to obtain a referral from GPs and the physician to manage this service, in which nurses from the local districts and specialized physicians from hospitals are also involved. Alternatively, a patient can have free access to any public hospital where palliative care and pain relief services are available. It is also possible for patients to approach a voluntary association delivering palliative care. These levels of care (specialist palliative care units within hospitals, hospices, day care centres and home care) are not available in all regions. Indeed, some regions have palliative care units within hospitals, which provide pain relief therapies. Non-profit-making and voluntary associations play an important role in providing further services, such as psychological support, bereavement support to families and so on. Regions differ also in the financing system for palliative care. In Lazio, for instance, a daily rate is given to providers as a reimbursement for both hospice and home care, while the cost of pharmaceuticals is not included since the local health authority is supposed to provide the appropriate drugs. In contrast, in Lombardy, there are different rates for each level of care (hospital and hospice care), with the hospital palliative care rate being higher than that of hospice care.

3.2. Continuity of primary care services

People may choose any GP or paediatrician they prefer at any time, provided that the physician’s list has not reached the maximum number of patients allowed (1500 for GPs and 800 for paediatricians). As a result, the actual freedom of choice depends on the prompt availability of a GP. Approximately 5–10% of patients change their physician every year.

According to the ICT Benchmarking Report in 2007 (Dobrev et al., 2008), the proportion of GPs reporting to have access to a computer in their consultation room is 84%. Only 2.4% of GPs reported using electronic networks for making appointments at other care providers for their patients, while 84.5% of GPs reported storing patient data electronically for administrative purposes. Finally, 7.2% of GPs declared they used electronic networks to transfer medical data to care providers/professionals.

Not all regions have enforced national guidelines as planned by a national programme for health care quality (Ministero della Salute, 2010a). This document contains guidelines for the systematic and periodic analysis of citizen satisfaction surveys, which, nevertheless, seem to have increased in the last few years. However, according to a Eurobarometer Survey from 2002 on public satisfaction with the health care system in the then EU15 countries, Italy remained below the EU average. The proportion of patients satisfied with GPs is 74.5% (European Commission, 2002).

At the regional level, available data on Italian citizens’ satisfaction in 2005 (ISTAT, 2007b) show that the regions with the least satisfied respondents are Calabria (35.9%), Puglia (28%) and Sicily (25.6%), while those with the highest levels of satisfaction are Bolzano Province (68.8%), Valle d’Aosta (59.6%), Trento Province (58.8%) and Emilia Romagna (46.8%). Satisfaction differs across the north–south divide, with the northern and central regions consistently obtaining above-average results, whereas all southern regions scores are below average.

3.3. Coordination of primary care services

Starting from 1996 and especially after the National Agreement renewal in 2000, several financial incentives have been provided to GPs to enhance quality of care and accessibility by developing new forms of inter-professional collaboration and working in group practices. Currently, the three types of team-working – association, network, and group medicine – imply an increasing level of collaboration and a progressively higher financial reward for GPs joining in (Fattore & Salvatore, 2010). Group medicine requires that GPs share a clinic or practice where care is provided; in group medicine and networks, unlike in associations, GPs share the clinical history of their patients through electronic medical records. Association implies only that individual practices ensure their opening hours are coordinated from Monday to Friday.

Starting from 2005 some regions, such as Emilia Romagna, Lombardia, Piemonte, Veneto and Toscana, have launched regional programmes for the development of organizational models based on the integration of different professionals, using different names such as primary care units in Emilia Romagna region, territorial units of primary care in Veneto region, health houses in Toscana region and many others where GPs, nurses and other practitioners deliver comprehensive health care in centres located outside the hospital.

A strong collaboration among GPs, social services and the public health department is developed and enhanced in most of the Italian regions. The only available data nationally dates back to a 2004 survey of the Ministry of Health. As of 2004, 59% of Italian GPs have joined a type of collaborative initiative, and 22% created a group practice (Ministero della Salute, 2004). More recent regional data of 2006 show that variability regarding four or more GPs working in the same building without medical specialists can range from 11.5% in Calabria to 35% in Umbria.

Concerning the relationship with specialists, GPs act as case managers for their patients (on the basis of a trust-based relationship). When a patient is discharged from the hospital, he/she receives a referral letter to be given to the GP so that he or she can be informed about the care delivered in hospital. However, specialists can directly call GPs and these latter also have free access to visit patients during their stay in hospitals. The need to ensure hospital beds turnover and follow-up care to minimize possible hospital readmissions has led to various regional approaches to proper discharge management, improving the overall continuity of care, although not homogeneously across the country.

3.4. Comprehensiveness of primary care services

Italian GPs and paediatricians are mostly involved in first-contact care, treatment and follow-up of most common diseases, preventive care and health promotion (see Table A15.2). Traditionally they have lost through time many technical procedures which were absorbed by outpatient services. Therefore they capitalized on good patient relationship management for low and medium health problems but were forced to delegate to other levels of care whenever faced with issues above a minimum technical level (also on the basis of medical laws, which require specialists to sign medical examinations and reports). More recently an increasing number of GPs and paediatricians are however adopting new technologies in support of diagnostic capabilities (such as ecography and testing tools).

Table A15.2

GPs’ involvement in delivery of various primary care services.

4.1. Quality of primary care

In Italy drug consumption (hospital sector excluded) was 924 DDD/1000 population for the year 2008. Differences in prescribing behaviour of GPs persist between northern and southern regions. The degree of adhesion to policies and guidelines regarding appropriateness of drug prescriptions launched by the state and regions may vary. The lowest rate of drug consumption is registered in the two autonomous provinces of Trento and Bolzano (691 and 784 DDD/1000 population) while the highest is registered in Sicily and Calabria (1034 and 1054 DDD/1000 population). A similar pattern can be observed for antibiotic prescription (Agenzia Italiana del Farmaco, 2009).

Fig. A15.4 shows admission rates that can be used as indicators for quality in primary care; they are related to some conditions where prompt diagnosis and treatment at primary care level can prevent unnecessary hospital admissions. Relatively high hospital admissions rates exist for patients with dehydration, kidney infections, perforated ulcer and asthma.

Fig. A15.4

Number of hospital admissions per 100 000 population with a primary care sensitive diagnosis in most recent year. Source: Ministero della Salute, 2010c.

The infant mortality rate can be used as indicator of quality of maternal and child health care as well as for the socioeconomic development of a country. During the twentieth century the infant mortality rate (IMR) declined dramatically in all developed countries. Italy also registered a remarkable reduction: in 2006 the IMR was 3.4 per 1000 live births, one of the lowest in Europe. Despite this important overall achievement, the IMR shows a large variability across the regions (ranging from 0.8 in Valle d’Aosta to 5.5 in Calabria), with higher rates in the southern regions (Osservatorio Nazionale sulla salute nelle regioni Italiane, 2009a).

The percentage of children receiving immunization in Italy is higher than 90% for the following diseases: diphteria, tetanus and pertussis 96.7%; measles, mumps and rubella 89.6%; hepatitis B 96.1%; polio 96.3% (OECD, 2009; Osservatorio Nazionale sulla salute nelle regioni Italiane, 2009b).

Concerning the main screening programmes for adults, the average percentage of women aged 50–60 who participated in breast screening programme in 2007 was 62.3%, taking into account the gap between percentage of northern regions (99.1% in Emilia Romagna) and southern regions (11.8% in Puglia). The same could be observed for cervical cancer screening, where the percentage of women aged 25–64 who participated in screening in 2007 was 27% in the south, 40% in the centre and 46.9% in the north of the country (Osservatorio Nazionale sulla salute nelle regioni Italiane, 2009b).