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
The general rules of the health service:
· Creation of a modern health consciousness with all
· Prevention of illness and industrial accidents; security
· 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
health insurance links:
There are 3 levels:
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)
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
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.
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
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.
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.
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
· services regarding health cures
· services, which include rehabilitations outside of
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
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).
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.
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.
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.
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
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.
· 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
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
· Group B: drugs with therapeutical meaning
· Group C: drugs, which do not belong to group A or
· Group H: drugs offered by hospitals
The amount of additional payments is connected with the group
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.