Italy has a strong North-South divide (rich North, poor South) and a quick changing politics with changing goverments. This has, of course influences on the health service.

The medical service

Italy has a governmental medical service. In 1970 Italy still had approx. 100 different health insurances, which was abolished in 1978. In that time the governmental medical service SSN (Servicio Sanitaris Nazionale) was introduced, which encompasses all citizens. Non-cash benefits and services are available free of charge. The original idea was to introduce the SSN in order to create a unique service offer, to get rid of the North-South divide and to lower the costs. However, this plan did not work out. The SSN was already subject of 4 reforms since its founding.
A basic principle is that health should be the fundamental right of everyone. It is not only the fundamental right of all people, it is also regarded as public interest of the state and it is also protected with the help of the SSN. All citizens (registered at the SSN) are entitled to receive health care. Everyone has to be treated with the same dignity, regardless of his social position. Everyone in need has to receive medical treatment.
The general rules of the health service:
· Creation of a modern health consciousness with all citizens
· Prevention of illness and industrial accidents; security at work
· Diagnosis and curing of illnesses; rehabilitation
· Food hygiene
· Protection against illnesses concerning stockbreeding
· Job-related further education for people employed within the sector of health service
· Protection of mother and child

In November 30, 1998, important changes within the medical service came into force. The health system became federalist. Regions became responsible for management and organisation and municipalities began to play a more powerful role.

Organisation

There are 3 levels:
· national
· regional
· local
The organisation is heavily decentralised. The regional government is responsible for planning, financing, control and supervision. The parliament, however, is deciding on the framework regarding the SSN. (very important is law no. 833 from 1978).

The levels in detail:

a) the national (central) level:
The institution of this level is the ministry of health. It is responsible for the SSN objectives (health plan). The ministry of health, however, has been using the financial resources from the Sanita Nazionale fond (FSN) for other levels until the year 2004. In the beginning of 2004 this fond was abolished. Now the regions will receive full autonomy step by step until 2013. A solidarity fond for compensation of weaker regions is new on national level.
Another task of the ministry of health is the control of the drug market and research. It also coordinates the Instituti di Rivovero e Cura a Carattere Scientifico (IRCCS) – a cooperation of 16 public and private hospitals dedicated to research.
Another area of responsibility are national prevention programs (e.g. information on vaccination). The responsible authority is the supreme insitution for prevention and work security.
It is also head of 10 zoological intitutes and therefore responsible for veterinary medicine.

b) the regional level:
The regional government draws up a regional health plan every 3 years. It includes the way how to distribute financial resources to local health units or hospitals. They adapt themselves to the health plans of the USL (see c) local level). The regional government also performs a controlling function regarding efficiency, quality and of provision of service through public and private health organisations. They also have legislative competence for certain areas.

c) the local level:
On the local level there are the various USL (Unita Sanitarie Lokale). (You also find often the abbreviation ASL – Aziende Sanitarie Lokale.) There exist more than 200 USL, approx. 50000 – 200000 inhabitants are assigned to each of them. The various USL are self-governing. The parliaments of the municipalities take according decisions and elect the president of the USL.
On this level health benefits are still provided by trusts, hospitals of the IRCCS and private hospitals.
Every citizen has to register at the USL, which is responsible for his domicile. It is necessary to come in person. When registering you receive a “health card” that makes it possible for the insured party to choose a general practioner (“medico die base“ – a certain doctor as primary contact person) freely, as well as the procuring of various licences, necessary for health care. This card also makes it possible to receive the granted exemption, dependend on the illness.

Financing

Usually a governmental health service is financed through public resources but this is not completely the case in Italy. Only 37.5% comes from public resources, 40.8% comes from health insurance contributions paid by the employer (2.88% of the gross earnings) and the rest from additional private payments. As the FSN will only be abolished step by step (see organisation, national level), the regions are responsible for financial matters.
The cash flow look as follows:

SSN Government Population
central level
regional level
Ministry of health, national budget, income tax
National solidarity fond, sales tax **)
The various regional ministries, regional budget, IRAP *), 10-35% national, 65-90% regional
Additional regional income tax ***) and other regional taxes

*) IRAP: Imposta Regionale sulla Attività Produttive; this is a regional tax on employers’ profit and on salaries of member of the ÖD:
**) 74.3% are added up to the natioal budget and 25.7% to the regional budget
***) regional income tax IPREF; the regions decide on the amount, but the maximum is 1.4%: The national income tax will be reduced with the same % rate as a countermove, in order to avoid an additional burden for the citizen.

Services

Cash benefits/sickpay:
Is only received by workers (employees receive a compulsory continuing payment of wages of a minimum of 3 months.) In order to receive sickpay, an inability to work is required – confirmed by a doctor. The maximum payment period is 6 months. The patient receives 50% of the gross earnings between day 1 and day 20, and from day 21 he receives 66.66% of the gross earnings.

Non-cash benefits:
All citizens are entitled to receive non-cash benefits. The insured party is able to choose a general practioner (medico di base). Regular services in governmental health centres or at statutory health insurance physician are carried out without additional payments. Additional payments, however, are required for many kinds of medicine as well as for specialist services; in fact for:
· services regarding pharmaceutical care (go to german Zahnversicherung)
· services through an established specialist
· services for partly stationary hospital treatments for analysis/examination
· services regarding health cures
· services, which include rehabilitations outside of the hospital
The regions are also able to adopt emergency treatments in their catalogue (without a continuing treatment in the hospital)
The costs for dental treatments will not be covered. The citizen has to pay the entire amount by himself.

Doctors and hospitals:

a) medico die base / family doctor:
Family doctors are responsible for the primary care and refer the patient to the specialist, if necessary. Family doctors work either in the out-patient department of the USL or they are self-employed and are bound by contract to the USL. The densitiy of doctors is relatively high.

Density of doctors per 100000 inhabitants:

Italy and Ireland 2001; Germany 2000; Switzerland 2002;
A family doctor gets paid with a per capita premium per patient, which is the main part of his payment. This can be increased by additional fees through special treatments (e.g. treatment of a chronic ill person).

b) specialists:
The payment of specialists is carried out partly by the hour, partly after single service. If you visit a specialist, you generally have to pay a fee. The amount of this fee (between 13 and 36€) is laid down by the various regions. The specialists work either in public hospitals or they are self-employed. Some specialists have private offices but the health insurance doesn’t cover the costs in this case.
In case of a visit at the gynaecologist or eye specialist the patient does not need a referral through the family doctor. The patient can go directly to the specialist.

Medical education:
In Italy the study of medicine lasts for 6 years and it ends with a state examination. With your successful final examination you receive a professionalism authorization. In order to register for the state examination, you have to successfully accomplish a 6 month internship at a university clinic (or at the National Health Service). You can already do your internship during your 6-year study period. If you need further education in order to become a specialist, you can use the technical college for further education of the university. If you want to become a specialist and work within the National Health Service, you have to complete a postdoctoral education after your studies, which has to last at least 2 for years.

Medical representation of interests:
Every doctor is compulsory member of the General Medical Council (regional) and listed in the index of doctors. The General Medical Councils supervise the ethics of the profession and they also have disciplinary powers. They give advices to doctors regarding fee negotiations.
Furthermore there are various medical unions for the medical representation of interests.

c)hospitals:
Most of the hospitals are operated by the USL. The biggest ones, however, possess so-called “trusts” as financial autonomy and conclude contracts with the USL.
This was introduced in 1994 with the aim to create a healthy competition within the hospital sector. There are also private hospitals, which are bound to the national health service by contracts.
USL hospitals are financed with the money of the USL.
Contracted hospitals receive their payments after annual negotiations about daily rates.

The current project (partly financed through the European Commission) is a virtual hospital. The aim is to improve the services and create a higher quality. Offers on the internet are:
· Clinical services of various special areas (e.g. medical advice)
· Non-clinical activities (e.g. e-commerce)
· Arranging of appointments
· Online advice/ online diagnosis
· Medical chat-line
· Overview of bed availability (Italy has a relatively small amount of hospital beds)
· Information for doctors and for the public

Drugs:
Drug supply belongs to the area of competence of the regions. Those are controlling the steps and decide about necessary additional payments and their amount.
There are 4 groups of different drugs:
· Group A: strong drugs for the treatment of chronic illnesses
· Group B: drugs with therapeutical meaning
· Group C: drugs, which do not belong to group A or B
· Group H: drugs offered by hospitals
The amount of additional payments is connected with the group classification.
People older than 65 and children up to 6 years are exempt from additional payments as well as the disabled and unemployed.

Expenses for drugs are relatively high when comparing with other European countries. Italy and France take the first place in this matter.

Figures (from 2003)

Italy has approx. 301300 inhabitants. The life expectancy is 76.9 years for men and 82.9 years for women. The infant mortality (per 1000 life-births) amounts to over 4%, which is relatively high. In 2002 public expenses for health services amounted to 8.5% of the GDP.