The Italian National Health Service (Servizio Sanitario Nazionale) was set up in 1978, with universal coverage, solidarity, human dignity, and health needs as its guiding principles. It is regionally based and organized at the national, regional, and local levels. Under the Italian constitution, 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, or LEA). The 19 regions and two autonomous provinces have the responsibility to organize and deliver 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 (NHS) 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 receive health services by paying for the costs of treatment.Public financing accounted for 75.8 percent of total health spending in 2014, with total expenditure standing at 9.1 percent of GDP. 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 in proportion to their contributions (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 whose resources are insufficient to provide essential levels of care.
The 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. Since the National Health Service does not allow people to opt out of the system and seek only private care, substitutive insurance does not exist, but complementary and supplementary private health insurance are 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 2014. Around 6 million people are covered by some form of voluntary health insurance (VHI), which generally covers services excluded under the LEA, offering 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. Tax benefits favor complementary over supplementary voluntary insurance.
There are two types of private health insurance: corporate, for which companies cover employees and sometimes their families, and noncorporate, with individuals buying insurance for themselves or their families. Policies, either collective or individual, are supplied by for-profit and nonprofit organizations. The market is characterized by three types of nonprofit organizations: voluntary mutual insurance organizations and corporate and collective funds organized by employers or professional associations for their employees or members. There is no information on the number of policies sold by each type of VHI provider, but nonprofit insurers cover the majority of the insured.
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 offered to all residents; examples include pharmaceuticals, inpatient care, preventive medicine, outpatient specialist care, home care, primary care, and hospice care. Negative lists identify services not offered to patients, such as cosmetic surgery; services covered only on a case-by-case basis, such as orthodontics and laser eye surgery; and services for which hospital admissions are likely to be inappropriate, such as cataract surgery. Regions can offer services not included at the essential levels of care but must finance them themselves.
Prescription drugs are divided into three tiers according to clinical effectiveness and, in part, cost-effectiveness. The first tier (classe A) includes lifesaving drugs and treatments for chronic conditions and is covered in all cases; the second (classe C) contains all other drugs and is not covered by the NHS. There is an additional tier (classe H) comprising drugs that can be delivered only in a hospital setting. The three tiers are updated regularly by the National Pharmaceutical Agency based on new clinical evidence. For some categories of drugs, therapeutic plans are mandated, and prescriptions must follow clinical guidelines.
Dental care is generally not covered, except for children up to 16 years old, vulnerable populations, and people in economic and emergency need.
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 each prescribed procedure or specialist visit up to a ceiling determined by law—currently at EUR36.15 (USD48.00).6 Therefore, a patient who receives two separate prescriptions (e.g., for an MRI scan and for a consultation with a gastroenterologist) pays EUR36.15 (USD48.00) for each prescription.
To address rising public debt, in July 2011 the government introduced, along with other economic initiatives, an additional EUR10 (USD13) copayment for each prescription. Copayments have also been applied to outpatient drugs at the regional level, and a EUR25 (USD33) copayment has been introduced for “unnecessary” 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 EUR129 (USD172) in a given year are eligible for a tax credit equal to roughly one-fifth of their spending, but there are no caps. In 2015, 22 percent of total health spending was paid out-of-pocket, mainly for drugs not covered by the public system and for dental care.7 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 under age 6 and over age 65 who live in households with a gross income below a nationally defined threshold (approximately EUR36,000, or USD48,000); 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, and pediatricians, under contract and paid a capitation fee based on the number of people on their list.8 Local health units also can pay additional allowances for the delivery of planned care to specific patients (e.g., home care to chronically ill patients), for reaching performance targets (e.g., to reward effective cost containment for prescribed pharmaceuticals, laboratory tests, and therapeutic treatments), or for delivering additional treatments (e.g., medications, flu vaccinations).
Capitation is adjusted for age and accounts for approximately 70 percent of overall payment. The variable portion comprises fee-for-service payment for specific treatments, including minor surgery, home care, preventive activities, and care of chronically ill patients. On average, the gross income of a GP ranges between EUR80,000 (USD107,000) and EUR120,000 (USD160,000), depending on list size. The 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 2012, there were approximately 53,000 GPs and pediatricians (33.6% of all practitioners working for the NHS) and 104,600 hospital clinicians (66.4%).9 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 fall below a predetermined spending maximum or consumption target. 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, in which 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 and pediatricians to access the same patient electronic health record system; and advanced group practice, in which GPs and pediatricians share the same office and patient health record system and are able to provide care to patients beyond individual catchment areas. In 2012, approximately 70.3 percent of GPs and 61.2 percent of pediatricians were working in a team.10 Group practices typically range from three to eight GPs.
General practitioners working in base group practices receive an additional EUR2.58 (USD3.70) for each patient registered in their list, while GPs in a network practice receive EUR4.70 (USD6.30) (the payment for pediatricians is EUR8.00, or USD11.00). Lastly, GPs working in a group practice receive EUR7.00 (USD10.00) and pediatricians EUR9.00 (USD12.00). General practitioners or pediatricians receive an additional payment of EUR4.00 (USD6.70) for employing a nurse and EUR3.50 (USD4.70) for a secretary. Some regions are promoting care coordination by asking their GPs to work in groups comprising 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 arrangement is encouraged by additional payments to GPs per patient and by supplying teams with personnel.
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 a choice of any public or private accredited hospital but are not given a choice of 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 EUR32 (USD43). 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 the visit or test.
After-hours care: In the case of after-hours emergency care, or when a consultation with a GP is not possible, service is provided by the emergency medical service (guardia medica), staffed by “continuous-care physicians” (medici di continuità assistenziale). The hourly rate, negotiated between the GP trade unions and the government, is approximately EUR25 (USD33). Following examination and initial treatment, the doctor can prescribe medications, issue employees’ medical certificates, and recommend hospital admission. The service normally operates at night and on weekends.
Hospitals: Depending on the region, public funds are allocated by local health units to public and accredited private hospitals. In 2012, there were approximately 187,000 beds in public hospitals and 45,500 in private accredited hospitals.11 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 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, in order to contain costs and as an incentive to increase admissions.
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 2012, there were 1,938 residential facilities and 819 semiresidential facilities, providing care to approximately 69,000 patients.12 The 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 the provision of mental health care; a few regions have experimented with assigning the responsibility of low-complexity cases (mild depression) to general practitioners.13
Long-term care and social supports: Patients are generally treated in residential (approximately 180,000 beds in 2012) or semiresidential (14,000 beds) facilities or in home care (approximately 634,000 cases). Residential and semiresidential services provide nurses, physicians, specialist care, rehabilitation services, medical therapies, and devices. Patients must be referred to receive residential care. Cost-sharing for residential services varies widely according to region but is generally determined by patients’ 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 designed not 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 EUR500 (USD714) per month.
Care vouchers: 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 EUR300 and EUR600 (USD426 to USD857) 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 late 1990s and has contributed to an increase in services such as hospices, day care centers, and palliative care units within hospitals. In 2012, there were 176 hospices, with approximately 1,800 beds. But much still needs to be done to ensure the diffusion of palliative care services because disparities persist: northern regions cared, on average, for 54 patients per 100,000 residents, while in central and southern regions the rate fell to 27 patients.
What are the key entities for health system governance?
The Ministry of Health is currently divided 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., the National Health Council, the 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 to 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. 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 for regional health departments (see below). Regional governments periodically sign “Pacts for Health” (Patto per la Salute) with the national government linking additional resources to the achievement of health care planning and expenditure goals The 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, others by emphasizing 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 the quality of services from the citizen’s point of view. Italy is the sixth largest country in Europe. The majority of the population has a high standard of living and quality of life resulting from well-established health policies and welfare measures. Italy has the second highest average life expectancy in the EU, reaching 79.4 years for men and 84.5 years for women (2011). The healthcare system in Italy is a regionally based national health service known as Servizio Sanitario Nazionale (SSN). It provides universal coverage, with public healthcare free of charge at the point of service. Healthcare facilities vary in terms of quality in different regions of Italy.
Getting the right health insurance
If you are employed in Italy, your employer is obliged to pay for your health insurance. You can pay a visit to the nearest local health authority, the Azienda SanitELocale (ASL), and then register with your doctor. Once you are registered, a health card and a health number will then be issued. This will serve as your ticket for free visits to your doctor. In turn, your doctor will then issue you with the proper prescriptions, along with any necessary referrals. On the other hand, if you are a European Union citizen that is paying a visit to Italy, take advantage of the reciprocal healthcare agreements. Before you arrive, you are required to apply for form E111, (the certificate of entitlement to treatment), at least three weeks prior to travelling. However, if you are visiting Italy and you are not a European Union citizen, you are required to have private insurance cover. Upon arrival, you have eight days to visit the local police station and present a health policy that is only valid within the duration of your stay.
Drugs and medical products
If you are in need of prescription medicines and other drugs, your family doctor will issue you a prescription that you can present to the pharmacy. Most pharmacies in Italy are small, family-run establishments and they only deal with medically related items. However, if you have state health cover, you will qualify for subsidised rates that reduce the cost of your medicines; otherwise you are required to pay in full. If you are taking a prescription drug on a regular basis, it may be worthwhile to find out the medicines’ generic name as brands normally vary from one country to another.
Private or state cover?
Italians and expatriates prefer to take private health insurance cover over and above the basic state cover. With private insurance, you can freely choose your own doctor and specialist and be treated at private hospitals, thus avoiding those long queues to get an appointment for a medical specialist. Private hospitals in Italy have excellent accommodations, some which are comparable to five-star hotels. Although the comfort and the quality of service from private hospitals are superior, the medical care is likely to be similar to that of public hospitals. It should also be noted that private hospital treatments in Italy are very expensive.
Other Italian health services
Through referrals from medical practitioners, medical auxiliary services by nurses, chiropodists, or physiotherapists are available, depending on where you live. There are some locations in which a nurse will be obliged to charge a fee for a home visit. Additionally, free counselling for relationship and family problems is also available through a network of different local health centres, wherein appointments can be made without requiring a doctor’s referral.
Health Care for Immigrants
Asylum seekers and beneficiaries of international protection must enrol in the National Health Service. They enjoy equal treatment and full equality of rights and obligations with Italian citizens regarding the mandatory contributory assistance provided by the National Health Service in Italy. There is no distinction between asylum seekers benefitting from material reception conditions and those who are out of the reception system, since all asylum seekers benefit of the National Health System.
The right to medical assistance is acquired at the moment of the registration of the asylum request but very often the exercise of this fundamental right is hindered and severely delayed, depending upon the attribution of the tax code, assigned by Questuras when formalising the asylum application. This means that it reflects the delay in proceeding to “C3”, in some territories corresponding even to several months (see section on Registration).
Pending enrollment, asylum seekers only have access to sanitary treatments ensured by Article 35 of the Consolidated Act on Immigration (TUI) to irregular migrants: they have access to emergency care and essential treatments and they benefit from preventive medical treatment programmes aimed at safeguarding individual and collective health.
During the 2016 the delay has been accentuated because of the attribution to asylum seekers of special tax codes other than the ones attributed to other people, consisting in numerical and not alphanumeric codes. Insufficient information provided for public offices and the failure to update the computer systems has effectively prevented access to this as to other fundamental rights.
Asylum seekers have to register with the national sanitary service in the offices of the health board (ASL) competent for the place they declare to have a domicile. Once registered, they are provided with the European Health Insurance Card, tessera sanitaria (TEAM), whose validity is related to the one of the permit of stay. Registration entitles the asylum seeker to the following health services:
- free choice of a general doctor from the list presented by the ASL and choice of a paediatrician for children (free medical visits, home visits, prescriptions, certification for access to nursery and maternal schools, obligatory primary, media and secondary schools);
- special medical assistance through a general doctor or paediatrician’s request and on presentation of the health card;
- midwifery and gynaecological visits at the “family counselling” (“consultorio familiare”) to which access is direct and does not require doctors’ request;
- free hospitalisation in public hospitals and some private subsidised structures.
The right to medical assistance should not expire in the process of the renewal of the permit of stay, however in practice, asylum seekers with an expired permit of stay have no guarantee of access to non-urgent sanitary treatments for a significant length of time due to the bureaucratic delays in the renewal procedure. This also means that where asylum seekers do not have a domicile to renew their permit of stay, for example because their accommodation right has been revoked, they cannot renew the health card.
Medical assistance is extended to each regularly resident family member under the applicant’s care in Italy and is recognised for new-born babies of parents registered with the National Health System. Regarding the effective enjoyment of health services by asylum seekers and refugees, it is worth noting that there is a general misinformation and a lack of specific training on international protection among medical operators. In addition, medical operators are not specifically trained on the diseases typically affecting asylum seekers and refugees, which may be very different from the diseases affecting Italian population.
One of the most relevant obstacles to access health services is the language barrier. Usually medical operators only speak Italian and there are no cultural mediators or interpreters who could facilitate the mutual understanding between operator and patient. Therefore asylum seekers and refugees often do not address their general doctor and go to the hospital only when their disease gets worse. These problems are worsening because of the severe conditions of the accommodation centres and, as highlighted by MSF in the report “Fuoricampo” published on March 2016 of the informal accommodation in the metropolitan areas.
Contribution to health care costs
Asylum seekers benefit from free of charge health services on the basis of a self-declaration of destitution submitted to the competent ASL. The medical ticket exemption is due to the fact that asylum seekers are treated under the same rules as unemployed Italian citizens, but the practice is very different throughout the country. In all regions, the exemption is valid for the period of time in which applicants are unable to work, corresponding by law to 2 months from the submission of the asylum application. During this period they are assimilated to unemployed people and granted with the same exemption code.
For the next period, in some regions such as Lazio, Veneto and oscana, asylum seekers are no longer exempted from the sanitary ticket because they are considered inactive and not unemployed. In other regions such as Piemonte and Lombardia, the exemption is extended until asylum seekers do not actually find a job. In order to maintain the ticket exemption, asylum seekers need to register in the registry of the job centres (“centri per l’impiego”) attesting their unemployment.
On 18 April 2016, ASGI together with other NGOs sent a letter to the Ministry of Health requesting that effect be given to to Article 17(4) of the recast Reception Conditions Directive, according to which asylum seekers may be required to contribute to the costs for health care only if they have sufficient resources, for example if they have been working for a reasonable period of time. ASGI also asked to consider that from the approval of LD 150/2015 on granting the right to the exemption from participation in health spending, there can no longer be a distinction between the unemployed and the inactive. As of 9 of May 2016, the Ministry of Health replied to have involved the Ministry of Economy and the Ministry of Labour and Social Policy in order to achieve a uniform interpretation of the aforementioned rules.
Specialised treatment for vulnerable groups
Asylum seekers suffering from mental health problems, including torture survivors, are entitled to the same right to access to health treatment as provided for nationals by Italian legislation. In practice, they may benefit from specialised services provided by the National Health System and by specialised NGOs or private entities. In order to ensure the protection of the health of foreign citizens in Italy, ASGI has collaborated with the Italian Society of Migration Medicine (SIMM) since 2014, monitoring and reporting cases of violation of the constitutional right to health.
From 2015, ASGI also collaborates with MSF, providing legal support for migrants victims of violence. As of April 2016, the two organisations have started a project in Rome opening a centre specialising in the rehabilitation of victims of torture. The project is intended to protect but also to assist in the identification of victims of torture who, without proper legal support, are unlikely to be treated as vulnerable people.