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Italy Health System Review Health Systems in Transition Vol. 11 No. 6 2009 Italy Health system review Alessandra Lo Scalzo • Andrea Donatini Letizia Orzella • Americo Cicchetti Silvia Profili • Anna Maresso Anna Maresso (Editor) and Elias Mossialos (Series editor) were responsible for this HiT profile Editorial Board Editor in chief Elias Mossialos, London School of Economics and Political Science, United Kingdom Series editors Reinhard Busse, Berlin University of Technology, Germany Josep Figueras, European Observatory on Health Systems and Policies Martin McKee, London School of Hygiene and Tropical Medicine, United Kingdom Richard Saltman, Emory University, United States Editorial team Sara Allin, University of Toronto, Canada Matthew Gaskins, Berlin University of Technology, Germany Cristina Hernández-Quevedo, European Observatory on Health Systems and Policies Anna Maresso, European Observatory on Health Systems and Policies David McDaid, European Observatory on Health Systems and Policies Sherry Merkur, European Observatory on Health Systems and Policies Philipa Mladovsky, European Observatory on Health Systems and Policies Bernd Rechel, European Observatory on Health Systems and Policies Erica Richardson, European Observatory on Health Systems and Policies Sarah Thomson, European Observatory on Health Systems and Policies Ewout van Ginneken, Berlin University of Technology, Germany International advisory board Tit Albreht, Institute of Public Health, Slovenia Carlos Alvarez-Dardet Díaz, University of Alicante, Spain Rifat Atun, Global Fund, Switzerland Johan Calltorp, Nordic School of Public Health, Sweden Armin Fidler, The World Bank Colleen Flood, University of Toronto, Canada Péter Gaál, Semmelweis University, Hungary Unto Häkkinen, Centre for Health Economics at Stakes, Finland William Hsiao, Harvard University, United States Alan Krasnik, University of Copenhagen, Denmark Joseph Kutzin, World Health Organization Regional Office for Europe Soonman Kwon, Seoul National University, Republic of Korea John Lavis, McMaster University, Canada Vivien Lin, La Trobe University, Australia Greg Marchildon, University of Regina, Canada Alan Maynard, University of York, United Kingdom Nata Menabde, World Health Organization Regional Office for Europe Ellen Nolte, Rand Corporation, United Kingdom Charles Normand, University of Dublin, Ireland Robin Osborn, The Commonwealth Fund, United States Dominique Polton, National Health Insurance Fund for Salaried Staff (CNAMTS), France Sophia Schlette, Health Policy Monitor, Germany Igor Sheiman, Higher School of Economics, Russian Federation Peter C. Smith, Imperial College, United Kingdom Wynand P.M.M. van de Ven, Erasmus University, The Netherlands Witold Zatonski, Marie Sklodowska-Curie Memorial Cancer Centre, Poland Health Systems in Transition Alessandra Lo Scalzo, National Agency for Regional Healthcare, AGENAS Andrea Donatini, Emilia-Romagna Regional Health Authority Letizia Orzella, Regional Health Agency, Lazio Americo Cicchetti, Catholic University of the Sacred Heart, Faculty of Economics Silvia Profi li, LUISS Guido Carli, Rome Anna Maresso, European Observatory on Health Systems and Policies Italy: Health System Review 2009 The European Observatory on Health Systems and Policies is a partnership between the World Health Organization Regional Offi ce for Europe, the Governments of Belgium, Finland, Norway, Slovenia, Spain and Sweden, the Veneto Region of Italy, the European Investment Bank, the World Bank, the London School of Economics and Political Science, and the London School of Hygiene & Tropical Medicine. Keywords: DELIVERY OF HEALTH CARE EVALUATION STUDIES FINANCING, HEALTH HEALTH CARE REFORM HEALTH SYSTEM PLANS – organization and administration ITALY © World Health Organization 2009 on behalf of the European Observatory on Health Systems and Policies All rights reserved. The European Observatory on Health Systems and Policies welcomes requests for permission to reproduce or translate its publications, in part or in full. Please address requests about this to: Publications WHO Regional Offi ce for Europe Scherfi gsvej 8 DK-2100 Copenhagen Ø, Denmark Alternatively, complete an online request form for documentation, health information, or for permission to quote or translate, on the WHO/Europe web site at http://www.euro.who.int/PubRequest The views expressed by authors or editors do not necessarily represent the decisions or the stated policies of the European Observatory on Health Systems and Policies or any of its partners. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the European Observatory on Health Systems and Policies or any of its partners concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Where the designation “country or area” appears in the headings of tables, it covers countries, territories, cities, or areas. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specifi c companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the European Observatory on Health Systems and Policies in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. The European Observatory on Health Systems and Policies does not warrant that the information contained in this publication is complete and correct and shall not be liable for any damages incurred as a result of its use. Printed and bound in the United Kingdom Suggested citation: Lo Scalzo A, Donatini A, Orzella L, Cicchetti A, Profi li S, Maresso A. Italy: Health system review. Health Systems in Transition, 2009; 11(6)1-216 ISSN 1817-6127 vol. 11 No. 6 Health systems in transition Italy Contents Preface ............................................................................................................ v Acknowledgements ...................................................................................... vii List of abbreviations ..................................................................................... ix List of tables, fi gures and boxes ..................................................................xiii Abstract ...................................................................................................... xvii Executive summary .....................................................................................xix 1. Introduction ................................................................................................1 1.1 Geography and sociodemography ................................................. 1 1.2 Economic context .......................................................................... 2 1.3 Political context ............................................................................. 8 1.4 Health status ................................................................................ 12 2. Organizational structure ...........................................................................17 2.1 Overview of the health care system .............................................17 2.2 Historical background ..................................................................17 2.3 Organizational overview ..............................................................24 2.4 Decentralization and centralization ............................................. 30 2.5 Patient rights and empowerment ................................................. 31 3. Financing ..................................................................................................39 3.1 Health care expenditure ............................................................... 40 3.2 Population coverage and entitlement ...........................................47 3.3 Revenue collection and sources of funding ................................. 49 3.4 Pooling of funds ...........................................................................58 3.5 Purchasing and purchaser–provider relations ..............................61 3.6 Payment mechanisms .................................................................. 62 4. Regulation and planning .......................................................................... 71 4.1 Regulation ....................................................................................71 4.2 Planning and health information management ............................ 82 5. Physical and human resources ................................................................. 91 5.1 Physical resources ........................................................................91 5.2 Human resources ......................................................................... 98 iii Health systems in transition Italy 6. Provision of services .............................................................................. 105 6.1 Public health .............................................................................. 105 6.2 Primary/ambulatory care ............................................................111 6.3 Secondary/inpatient care .............................................................116 6.4 Pharmaceutical care ................................................................... 122 6.5 Rehabilitation/intermediate care ................................................136 6.6 Long-term
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