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State of Health in the EU Country Health Profile 2017

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on Health Systems and Policies a partnership hosted by WHO The Country Health Profile series Contents The State of Health in the EU profiles provide a concise and 1 • HIGHLIGHTS 1 policy-relevant overview of health and health systems in the EU 2 • 2 Member States, emphasising the particular characteristics and 3 • RISK FACTORS 4 challenges in each country. They are designed to support the efforts of Member States in their evidence-based policy making. 4 • THE HEALTH SYSTEM 6 5 • PERFORMANCE OF THE HEALTH SYSTEM 9 The Country Health Profiles are the joint work of the OECD and 5.1 Effectiveness 9 the European Observatory on Health Systems and Policies, in 5.2 Accessibility 12 cooperation with the . The team is grateful for the valuable comments and suggestions provided by Member 5.3 Resilience 13 States and the Health Systems and Policy Monitor network. 6 • KEY FINDINGS 16

Data and information sources The data and information in these Country Health Profiles are The calculated EU averages are weighted averages of the based mainly on national official statistics provided to 28 Member States unless otherwise noted. and the OECD, which were validated in 2017 to ensure the highest standards of data comparability. The sources and To download the Excel spreadsheet matching all the methods underlying these data are available in the Eurostat tables and graphs in this profile, just type the following Database and the OECD health database. Some additional data StatLinks into your Internet browser: also come from the Institute for Health Metrics and Evaluation http://dx.doi.org/10.1787/888933593627 (IHME), the European Centre for Disease Prevention and Control (ECDC), the Health Behaviour in School-Aged Children (HBSC) surveys and the Health Organization (WHO), as well as other national sources.

Demographic and socioeconomic in Italy, 2015

Italy EU

Demographic factors Population size (thousands) 60 731 509 175 Share of population over age 65 (%) 21.7 18.9 Fertility rate¹ 1.3 1.6

Socioeconomic factors GDP per capita (EUR PPP2) 27 800 28 900 Relative poverty rate3 (%) 13.4 10.8 rate (%) 11.9 9.4

1. Number of children born per woman aged 15–49. 2. (PPP) is defined as the rate of currency conversion that equalises the purchasing power of different currencies by eliminating the differences in price levels between countries. 3. Percentage of persons living with less than 50% of median equivalised disposable income.

Source: Eurostat Database.

Disclaimer: The opinions expressed and arguments employed herein are solely those of the authors any territory, to the delimitation of international frontiers and boundaries and to the name of any and do not necessarily reflect the official views of the OECD or of its member countries, or of the territory, or . European Observatory on Health Systems and Policies or any of its Partners. The views expressed Additional disclaimers for WHO are visible at http://www.who.int/bulletin/disclaimer/en/ herein can in no way be taken to reflect the official opinion of the . This document, as well as any data and map included herein, are without prejudice to the status of or over

© OECD and World Health Organization (acting as the host organization for, and secretariat of, the European Observatory on Health Systems and Policies) 82.7 82.7 PPP) (EUR spending capita Per people with life-threatening conditions. life-threatening with people treating in is effective system care health the that suggesting countries, EU in lowest the of one remains Italy in mortality Amenable Effectiveness objective of providing access to this expanded benefit basket to all residents. all to basket benefit expanded this to access of providing objective ambitious the achieve to regions among resources allocate to system anew designing and of funding arecentralisation fostering also is government central The basket. benefit health national the expand and reform to managed has Italy constraints, budget tight Under groups. socioeconomic and regions across exist disparities although , in highest the is among people of Italian The €2 000 €3 000 180 160 100 120 €1 000 140 Amenable mortality per 100 000 population 000 100 per mortality Amenable 80 2005 €0 1 118 175 2005 YEARS Highlights Binge drinking Binge Life expectancy at birth, years at birth, expectancy Life Overweight/ 2007 Smoking obese % of children in 2014 in children % of % of adults in 2014 in adults % of 2009 80 77 82 79 83 78 81 7% 2000 2011 77.3 79.9 18% 20% 2013 IT IT IT IT IT IT 80.6 82.7 126 2015 90 2015 EU EU 2014 EU EU EU Health systemperformance Health system Risk factors Health status and income group. group. income and by largely varies Italy in care health to However, access residents. foreign and citizens all covers automatically Health National Italian The Access EU IT care. dental and pharmaceuticals for pay to used mainly are 2015) in of 15% and average EU the to compared (23% high is relatively spending out-of-pocket free, are services of essential set acore Although 9.1% 2797. of 9.9%. of average EUR of GDP, equals EU average This the below also EU the 2015, in lower than is 10% capita per 2502 Italy, in at EUR spending Health average. EU the above are and grown have children among problems or obesity overweight adults, in low levels to contrast in hand, other the On countries. EU other most in lower than much is also consumption alcohol heavy regular reporting of adults proportion The average. EU the below well is fell and also adult per consumption alcohol Overall 2000. in 25% from down and average EU day, the below every slightly tobacco smoked Italy in 2014,In of adults 20% persist. gaps status socioeconomic and gender However, substantial diseases. cardiovascular from mortality in by reductions mainly driven were gains expectancy Life . after EU the in highest second is the which 2000, in years 79.9 2015, in from years 82.7 reached Italy in at birth expectancy Life 0% % reporting unmet medical needs, 2015 needs, medical unmet % reporting High income All 8% Low income STATE OFHEALTH INTHEEU: COUNTRY HEALTH PROFILE2017 –ITALY 16% and improve quality of care. quality improve and accountability increase to implemented being are measurements performance national New ageing. population tackle to trained being are nurses designed. been has spending health regional in equity increase to system A new Resilience Highlights . 1

Italy 2 . Health in Italy

Italy 2 Health in Italy

Life expectancy at birth in Italy is the second Most of the life expectancy gains in Italy since 2000 were driven by highest among EU countries reduced mortality rates after the age of 65. at age 65 can expect to live longer but with less disability-free years than other At 82.7 years, life expectancy at birth in Italy is the second highest EU people at age 65. In 2015, an Italian woman at the age of 65 in the EU (after Spain) and two years longer than the EU average has a life expectancy of 22.2 years, while the life expectancy of a (Figure 1). Life expectancy at birth increased by 2.8 years between man at the same age is 18.9 years. At age 65, women can expect 2000 and 2015. As in other EU countries, a substantial gender gap to live only about one-third (7.5 years) of their remaining life free remains, with life expectancy for women about five years higher of disability, while men can expect to live about 40% (7.8 years) of than for men. Disparities by socioeconomic status also persist. the rest of their life disability-free.2 Highly educated Italians have a life expectancy at birth that is four years higher than Italians who have not completed their secondary education.1 Figure 1. Life expectancy at birth in Italy is two years above the EU average Italy Years 2015 2000 90 82.7years of age

85 EU Average 80.6 years of age 83.0 82.7 82.4 82.4 82.2 81.9 81.8 81.6 81.6 81.5 81.3 81.3 81.1 81.1 81.0 80.9 80.8 80.7 80.6

80 78.7 78.0 77.5 77.5 76.7 75.7 75.0 74.8 74.7 75 74.6

70

65

60 EU Italy Spain Ireland Czech Slovak Republic

Source: Eurostat Database.

Mortality continues to be driven by Deaths from Alzheimer’s disease and other dementias have cardiovascular diseases and cancer increased substantially since 2000, due to , but also as a result of better diagnosis and an improved recording of Close to two-thirds of all deaths in Italy were attributable to either different forms of dementia as the primary cause of . cardiovascular diseases or cancer in 2014 (Figure 2). Cardiovascular diseases represent the main causes of death among women (40%) followed by cancer (24%), while for men one-third of deaths are Italy is facing a high burden of chronic related to cardiovascular diseases and another one-third to cancer. conditions mainly related to population ageing … When looking at trends in more specific causes of death, heart diseases and stroke continue to be the leading causes in 2014 In addition to the high burden of disease caused by cardiovascular (Figure 3). Lung cancer is still the leading cause of cancer mortality, diseases and cancer, musculoskeletal conditions (including low back followed by colorectal cancer, breast cancer and pancreatic cancer. and neck pain), diabetes and ageing-related conditions, including falls and Alzheimer’s diseases and other dementias, are

1. Lower education levels refer to people with less than primary, primary or lower secondary education (ISCED levels 0–2) while higher education levels refer to people with 2. These are based on the indicator of ‘healthy life years’, which measures the number of tertiary education (ISCED levels 5–8). years that people can expect to live free of disability at different ages.

STATE OF HEALTH IN THE EU: COUNTRY HEALTH PROFILE 2017 – ITALY Health in Italy . 3

Figure 2. Cardiovascular diseases and cancer cause nearly two in every three deaths in Italy Italy

Women Men (Number of deaths: 308 869) (Number of deaths: 289 800)

3% 10% 5% 9% 4% Cardiovascular diseases 4% Cancer 4% 5% 33% 40% Nervous system (incl. dementia) 6% Respiratory diseases 8% Endocrine, metabolic system Digestive system 8% 5% External causes 33% 24% Other causes

Note: The data are presented by broad ICD chapter. Dementia was added to the nervous system diseases’ chapter to include it with Alzheimer’s disease (the main form of dementia).

Source: Eurostat Database (data refer to 2014).

Figure 3. Cardiovascular diseases remain the leading cause of death, but death from dementias is rising

2000 ranking 2014 ranking % of all deaths in 2014 1 1 Ischaemic heart diseases 12% 2 2 Stroke 10% 3 3 Other heart diseases 8% 4 4 Lung cancer 6% 5 5 Alzheimer and other dementias 4% 6 6 Lower respiratory diseases 3% 7 7 Diabetes 3% 8 8 Colorectal cancer 2% 9 9 Breast cancer 2% 10 10 Pancreatic cancer 1%

15 18 Liver diseases 1%

Source: Eurostat Database. determinants of disability-adjusted life years3 (DALYs) (IHME, 2016). …and a high prevalence of viral hepatitis Data from the European Health Interview Survey (EHIS) report that Data from the European Centre for Disease Prevention and Control around 5% of Italians live with asthma, more than 20% live with show that Italy has the highest rate of hepatitis C virus infections hypertension, and around 6.5% have diabetes. Wide inequalities in the general population, at 5.9% for first-time blood donors. Italy exist in the prevalence of these chronic diseases depending on also reports the highest hepatitis C virus infection rate among individuals’ of education. People with the lowest level of migrants from , at 7.1% (ECDC, 2016). education are almost four times as likely to live with depression, more than three times as likely to live with diabetes, and more than twice as likely to live with hypertension as those with the highest level of education.4

3. DALY is an indicator used to estimate the total number of years lost due to specific diseases and risk factors. One DALY equals one year of healthy life lost (IHME). 4. Inequalities by education may partially be attributed to the higher proportion of older people with lower educational levels; however, this alone does not account for all socioeconomic disparities.

STATE OF HEALTH IN THE EU: COUNTRY HEALTH PROFILE 2017 – ITALY Italy STATE OFHEALTH INTHE EU: COUNTRY HEALTH PROFILE2017 –ITALY Source: EurostatDatabase,based onEU-SILC (datarefer to2015). 2. Thesharesfor the totalpopulationandthehigh-incomeareroughlysame. 1. Thesharesfor the totalpopulationandthelow-income populationareroughlythesame. health good in being report of Two-thirds Italians 4. Figure of peopleinthelowest incomequintile. income quintileconsidertheirhealthtobegood,compared64% is smallerthaninothercountries:73%ofpeoplethehighest health existsbetweenhigh-andlow-income groups,butthisgap a rateclosetotheEUaverage(Figure 4). Agapinself-rated Two-thirds oftheItalianpopulationreportbeingingoodhealth, Most Italiansreportbeingingoodhealth 4 . United Kingdom Slovak Republic Health inItaly Luxembourg Netherlands Lithuania Romania² Germany Denmark Slovenia Hungary Portugal Bulgaria Belgium Sweden Estonia Finland Croatia Greece¹ Austria Ireland Poland Cyprus France Latvia Spain¹ Malta Italy EU 20 Low income 30 % ofadultsreportingtobeingoodhealth 40 50 Total population 60 70 High income 80 90 100 smokers. Ofgreaterconcern,theprevalenceofsmokingamong 25% ofmen,comparedwithjust15%women,aredaily Smoking remainsmuchmorecommonamongmenthanwomen: however, oneinfiveadultsItalyarestillregularsmokers. substantially, withtheratenow slightlybelow theEUaverage; The proportionofadultswhosmoke regularlyinItalyhasreduced adolescents remainslimited but progressinreducingsmokingamong Smoking amongadultshasdecreased, activity (2.5%)contributingthemost(IHME,2016). body massindex(6.1%),alcoholuse(4.2%)andlow physical factors, withdietaryrisks(11.2%),tobaccosmoking(9.5%),high (measured inDALYs) inItaly2015wasduetobehaviouralrisk (IHME) show thatalargepercentageoftheburdendisease Estimates fromtheInstitutefor HealthMetricsandEvaluation considerable impactonhealth The mainbehaviouralriskfactorshavea 3 Riskfactors lower proportionthaninmostotherEUcountries. old boys reportedhavingbeendrunkmorethanonceintheirlife, a and relativelylow: 14%of15-year-oldgirlsand19%15-year- Sweden). Alcoholconsumptionamongadolescentsisalsostable having thethirdlowest consumptionpercapita(afterGreeceand alcohol consumption(measuredby sales)isalsolow, withItaly the secondlowest proportion(afterCyprus)intheEU.Overall very low –just7%ofadultsreportedsuchexcessiveconsumption, single occasion,atleast onceamonthover thepastyear. 5. Bingedrinkingbehaviourisdefinedasconsuming sixormorealcoholicdrinksona issues health public important are adolescents among problems overweight and 5.Smoking Figure reporting regularheavyalcoholconsumption(bingedrinking Compared withotherEUcountries,theproportionofItalianadults Alcohol consumptionisrelativelylow warnings inlate2016(seeSection5.1). ban onsmokinginpublicplacesandtheintroductionofpictorial health measuresputinplacetocombatsmoking,suchasthe regular smokingin2013–14.Thisisdespiteaseriesofpublic in theEU)and20%of15-year-oldboys (thethirdhighest)reported in theEU:22%of15-year-oldgirls(thesecondhighestprevalence adolescents hasnotreducedmuch,witharateamongthehighest Physical activity,15-year-olds Obesity, adults Overweight/obesity, 15-year-olds 5 Smoking, 15-year-olds ) is of becomingoverweight orobeseinadulthood. overweight orobeseinchildhoodadolescenceisastrongpredictor physical activity(Figure among adolescentsinItalyislinked, atleastpartly,tolow levelsof all EUcountries.Thishighandrisingoverweight andobesityrate is particularlyhigh(26%),thefourth highestprevalenceamong proportion of15-year-oldboys inItalywhoareoverweight orobese gone upquiterapidlyandnow equalstheEUaverage(18%).The that theproportionofadolescentswhoareoverweight orobesehas more slowly thaninotherEUcountries.Butaparticularconcernis prevalence intheEU.Thoughobesityhasincreased,itdoneso Just over 10%ofItalianadultsareobese,thesecondlowest obesity adolescents adults, buthighandrisingamong Obesity ratesarerelativelylow among Health Statistics and HBSC survey in 2013–14. (Chart design: Laboratorio MeS). Laboratorio design: (Chart 2013–14. in survey HBSC and Statistics Health 2014), OECD around or in (EHIS Database Eurostat on based calculations OECD Source: Italy. for available not are adults among activity physical of measure acomprehensive on data Comparable areas. all in countries all in progress for room is there as area’ ‘target white the in is country No countries. EU other to compared performs country the better the centre the to is dot Note: The STATE OFHEALTH INTHEEU: COUNTRY HEALTH PROFILE2017 –ITALY Binge-drinking, adults 5). This is particularly concerning, since being 5). Thisisparticularlyconcerning,sincebeing Smoking, adults Drunkenness, 15-year-olds Risk factors . 5

Italy 6 . The health system

Italy 4 The health system

A highly decentralised National Health -oriented reforms). Since 2016, several regions have merged Service results in different organisational local health authorities into larger entities to achieve efficiency gains and improve quality of care through economies of scale and models and outcomes across regions better organizational integration. Despite the commitment to the Italy’s National Health Service is regionally based, with the central Health System being legally enforced, policy concerns have been government sharing responsibility for with the country’s raised over regional differences in population health status, and 19 regions and two autonomous . At the national level, the access and quality of health services (OASI, 2016). This calls for government exercises a stewardship role, controls and distributes an effective performance management of hospitals, clinics and the tax-financed health budget, and defines the national benefits professionals at regional level (OECD 2014). package (known as the ‘Essential Levels of Care’) that must be guaranteed to all citizens and foreign residents. Regions are Total health spending declined following the responsible for the organisation, planning and delivery of health services through local health authorities. Public hospital-based 2008 economic crisis but is now rising again are salaried employees. Italy spent 9.1% of its GDP on health in 2015. This translated to EUR 2 502 per capita (adjusted for differences in purchasing Regions substantial autonomy in how they structure their power), which was 10% below the EU average (Figure 6). Following health systems within the general framework established nationally the economic crisis of 2008, total health spending per capita in (building on previous decentralisation efforts and incomplete real terms remained flat or decreased, but it has started to increase

Figure 6. Italy spends 10% less than the EU average on health care

EUR PPP Per capita (le axis) Share of GDP (right axis) % of GDP

6 000 12

5 000 10

4 000 8

3 000 6

2 000 4

1 000 2

0 0 EU Italy Spain Malta Latvia France Cyprus Poland Ireland Greece Austria Croatia Finland Estonia Sweden Belgium Bulgaria Portugal Hungary Slovenia Romania Denmark Germany Lithuania Netherlands Luxembourg Czech Republic Slovak Republic United Kingdom

Source: OECD Health Statistics, Eurostat Database, WHO Global Health Expenditure Database (data refer to 2015).

STATE OF HEALTH IN THE EU: COUNTRY HEALTH PROFILE 2017 – ITALY people ineconomicor need. 6. Childrenupto16yearsold,peopleover 65yearsold,vulnerablepopulations,and groups in thebenefitpackageisdentalcare(except for specific population of chargeatthepointservice.Amongservicesnotincluded Italy’s healthcaresystemprovides universalcoverage, largelyfree groups package, exemptionsprotectvulnerable Despite someexclusionfromthebenefits tool toinducehospitalsbalancetheiraccounts. compulsory DeficitReductionPlans for hospitalsasanadditional budgets. Mostrecently,in2016,thecentralgovernment introduced instruments tofoster areductioninexpenditureandbalance imposition ofregional‘recovery plans’,whichcomprisevarious Regions withhealthbudgetdeficitsarealsotargetedviathe all ofthesemeasureshavebeenuniformly implementedthough. part ofacost-containmentandefficiency-promotingpackage.Not copayment levelsandthelistofreimbursablepharmaceuticals,as including restructuringlocalhealthunitsandhospitals,revising government’s BalduzziDecreeintroducedaseriesofmeasures, promoting theprescriptionofgenericdrugs.Alsoin2012, new healthservicesstandardsandregulations,suchasfurther EUR 2.1 billionannuallybetween2012and2015introduced for theNationalHealthServiceby betweenEUR 900millionand public debt.ASpendingReviewin2012ledtodecreasedfunding for manyyearsandforms partofwiderefforts toreducehigh In Italy,containingthecostofhealthcarehasbeenamajorconcern major priority Containing healthcarecostshasbeena insurance playsonlyamarginalrole. mostly directout-of-pocket payments,asvoluntaryprivatehealth spending, whileprivatesourcesmake up the remaining24%, again since2014.Publicsourcesaccountfor 76%oftotalhealth chronic diseases,whicharefullycovered. identifies apositivelistofservices for peoplesuffering from such asorthodonticsarenotcovered. Moreover, thepackage pocket orby subscribingtoprivateinsurance.Similarly,services 6 ), whichhastobepaidfor by householdseitheroutof those withchronicconditionsorfrailelderly). into othertypesofservicestomeetchangingneeds(e.g.carefor bed numbersandthetransformation ofsomeacutecarefacilities to 2.8bedsin2013)responsenationaltargetsreduceall rapidly since2000(from4.2bedsper1 000populationin Overall, thenumberofacutecarehospitalbedshasdeclined 2011). south tonorthisseekbetterqualitycare(MinistryofHealth, is widelyacceptedthatthemainreasonwhypatientsmove from patients ayearinsearchofhealthcare(andattractfarfewer). It regions ofCampania,CalabriaandSicilyloseatleast30000 obtain care.DatafromtheMinistryofHealthshow thesouthern regions, leadingtoflows ofpatientstonorth-centralregions technology andbetterperceivedqualityofcarethansouthern northern andcentralregionshavehighercapacity,moreadvanced pose achallengefor accesstoservices.Generally speaking, The importantdifferences inhealthcareresources acrossregions regional disparitiesandmobilityofpatients perceived qualityofcareresultinsignificant Variations inavailableresourcesand in primarycare. professional groups introduction ofnurse-led care patientsandthe the managementofchronic especially withregardto being strengthenedinItaly, The roleofnursesiscurrently (EU averageof2.3). among thelowest intheEU nurses perdoctor(1.5)is compared withanEUaverageof8.4).Consequently,theratio the densityofnursesisrelativelylow (6.1per1 000population 1 000 population)ishigherthantheEUaverage(3.6).Incontrast, Figure 7 shows thattheratioofdoctorstopopulation(3.8per The healthworkforce grewsteadilyover thepastdecade. The ratioofnursesperdoctorisverylow STATE OFHEALTH INTHEEU: COUNTRY HEALTH PROFILE2017 –ITALY The healthsystem . 7

Italy Italy STATE OFHEALTH INTHE EU: COUNTRY HEALTH PROFILE2017 –ITALY heart failure(CHF)andrespiratorydiseases. programmes, focusing onconditionssuchasdiabetes,congestive care, someregionsalsointroducedchronicdiseasemanagement approach. Furthermore,inaneffort toimprove thecoordinationof professionals, following amultidisciplinaryandmultiprofessional models ofgrouppracticewithfellow GPsand/orotherhealth been provided inrecentyearsfor GPstomove towards various (called theguardiamedica).Moreover, financial incentiveshave days aweekthroughtheprimarycareout-of-hoursservice services inhealthcentresareguaranteed24hoursaday/7 and toprescriberefer onlyasappropriate.Primarycare financial incentivestoactasagatekeeper andcarecoordinator Practitioner (GP)(orapaediatricianuptotheageof14),whohas primary care,andpeoplearerequiredtoregisterwithaGeneral well asprivateaccreditedproviders. Greatemphasisisplacedon as districtandregionalhospitalsuniversityhospitals) Health careservicesaredeliveredthroughpublicproviders (such coordination ofcare Strong primarycarewithafocus onbetter Source: hospital. in Austria In working those Portugal). in 30% includes only it around of as (e.g. doctors underestimated is practising of nurses of number number the of the Greece, and overestimation alarge in resulting practice, to licensed doctors all to refer data Greece, and Note: Portugal In of nurses alow density and of doctors 7. density high Figure arelatively has Italy 8

Practising nurses per 1 000 population, 2015 (or nearest year) . The healthsystem 10 15 20 Eurostat Database. Eurostat 0 5 1 Nurses Low Doctors Low Nurses High Doctors Low 2 PL Practising doctorsper1000population,2015(ornearestyear) RO UK IE SI HR BE 3 LU LV HU EU average:3.6 FI FR SK EE NL EU CY CZ DK Italy ES MT 4 BG DE SE LT PT 5 AT 6 EU average:8.4 Doctors High Doctors High EL Nurses High Nurses Low 7 through timelyandeffective healthcare. 7. Amenablemortalityisdefinedaspremature deathsthatcouldhavebeenavoided Europe in lowest the among are Italy in rates mortality Amenable 8. Figure performance treatment canbeusedasageneralmeasureofhealthcaresystem Mortality fromconditionsthatareconsideredamenabletomedical effective the Italianhealthcaresystemisgenerally Low amenablemortalityratessuggest that 5.1 EFFECTIVENESS amenable mortalityratestrendeddownward over thepastdecade. low mortalityratesfor bothmenandwomen(Figure stroke andbreast,cervicalothertreatablecancers,withrelatively with life-threatening conditions,suchasischaemicheartdisease, suggest thattheItalianhealthcaresystemiseffective indealing United Kingdom Slovak Republic Czech Republic Luxembourg Netherlands 5 Lithuania Germany Denmark Romania Slovenia Hungary Portugal Bulgaria Belgium Sweden Estonia Finland Croatia Austria Greece Ireland Poland Cyprus France Latvia Performance ofthehealthsystem Malta Spain Italy EU 7 . Therelativelylow ratesofamenablemortalityinItaly 0 Women 64.4 64.9 67.7 69.3 74.1 100 77.4 79.4 80.7 79.7 83.0 83.9 88.2 85.5 85.4 88.7 92.3 94.4 98.7 97.5 119.9 121.5 Age-standardised ratesper100000population 147.8 152.5 168.2 200 192.3 196.3 207.1 214.9 239.5 300 8). Moreover, 400 500 were amongthelowest inEurope2015. interventions. Similarly,mortalityratesfromstroke camedown and more timelytransportationtohospitalandeffective medical progress inreducingmortalityreflectsarangeoffactors,suchas with only7.6deathsper100admissionsin2015(Figure 9). This diseases) arethelowest amongEUcountriesreportingthesedata, myocardial infarction(AMI,themainform ofischaemicheart across regionsandhospitals.Deathsfollowing admissionfor acute of hospitalsinsavingthelivespeople,althoughvariationsarise Indicators ofqualitycaresuggestagenerallygoodperformance death ratesfromcardiovascular diseases A strongacutecaresectorcontributestolow Source: United Kingdom Slovak Republic Czech Republic Luxembourg Netherlands Eurostat Database (data refer to 2014). to refer (data Database Eurostat Lithuania Germany Denmark Romania Slovenia Hungary Portugal Bulgaria Belgium Sweden Estonia Finland Croatia Austria Greece Ireland Poland Cyprus France Latvia Malta Spain Italy EU STATE OFHEALTH INTHEEU: COUNTRY HEALTH PROFILE2017 –ITALY 0 Men 92.1 96.4 107.9 108.2 110.5 113.7 115.1 117.0 117.2 133.0 138.0 139.1 139.6 149.0 152.1 154.4 158.2 Age-standardised ratesper100000population 160.3 168.2 200 Performance ofthehealthsystem 229.0 242.5 278.2 335.9 350.7 361.3 400 388.8 415.0 473.2 501.2 . 9 600

Italy 10 . Performance of the health system

Italy Figure 9. In-hospital case-fatality rates following AMI prevent the need for hospitalisation. The Italian health care system decreased and are very low in Italy generally provides good-quality primary care for people with such chronic conditions, which is indicated by relatively low admission Age-sex standardised rate per 100 patients aged 45 years and over rates for such ambulatory care-sensitive conditions (Figure 10). 20 2005 2010 2015 18 Despite low screening rates, cancer survival 16 is among the highest in the EU 14

12 In recent years, several National Screening Plans were implemented

10 to strengthen monitoring and screening for the most common types of cancer – colorectal, breast and cervical. Following EU guidelines, 8 population-based screening programmes are offered free of 6 at regional level for target populations. 4

2 CONCORD Programme data show that five-year survival rates 0 following a diagnosis for several types of cancers increased in Italy

Spain Italy between 2000–04 and 2010–14 and remain higher than in EU10 Finland Sweden Portugal Denmark most EU countries for breast cancer (86%), colon cancer (64%) and Netherlands Luxembourg

Czech Republic cervical cancer (67%) in 2010–14. United Kingdom

Note: This indicator is based on patient-level data. Three-year average for Luxembourg. Preventable mortality has been reduced The EU average is unweighted. through public health policies targeted at OECD Health Statistics 2017. Source: tackling risky behaviours Death rates from many preventable causes of mortality have also Primary care is generally of good quality reduced in Italy, due, at least partly, to public health policies aimed Primary care’s ability to serve patients with chronic conditions is at reducing these risk factors. The number of deaths from alcohol- often used as an indicator of primary care performance. Ambulatory related diseases (excluding external causes) is very low – Italy had (or outpatient) care-sensitive conditions, such as asthma, chronic the fourth lowest rate (5.9 per 100 000 population compared to obstructive pulmonary disease (COPD), congestive heart failure an EU average rate of 15.7) in 2014. Italy reports a rate of deaths (CHF) and diabetes, are conditions for which accessible and effective from road transport accidents of 5.9 per 100 000 population, primary care can generally reduce the risk of complications and similar to the EU average.

Figure 10. Low hospitalisation rates point towards good-quality care for chronic conditions

Age-sex standardised rate per 100 000 population Congestive Heart Failure Diabetes Asthma & COPD 1,200

1,000

800

600

400

200

0 Italy Spain Malta EU21 France Poland Ireland Austria Finland Estonia Sweden Belgium Portugal Hungary Slovenia Denmark Germany Lithuania Netherlands Czech Republic Slovak Republic United Kingdom

Note: Rates are not adjusted by health care needs or health risk factors.

Source: OECD Health Statistics 2017 (data refer to 2015).

STATE OF HEALTH IN THE EU: COUNTRY HEALTH PROFILE 2017 – ITALY Performance of the health system . 11

Deaths from lung cancer were lower than the EU average, at 60.2 Italy recently introduced new measures to increase vaccination Italy deaths per 100 000 population in 2014 compared with 82.5. coverage among children to reduce the risk of epidemics of Policies have targeted smoking for the past 15 years, including infectious diseases (Box 1). the 2012 ban on smoking in all public and work places, and stronger restrictions on consumption for minors. However, smoking Efforts to reduce childhood obesity seem rates among teenagers remain too high (see Section 3). A recent to be working, although regional disparities European policy introduced pictorial warnings on packs in late 2016, targeting teenagers in particular. However, its effect might be persist diminished by the simultaneous release, in tobacco shops, of ‘pack The Italian government has taken steps to monitor and reduce the covers’ made specifically to hide the unsettling images on the new prevalence of overweight and obesity rates among children. The packaging. surveillance system ‘Okkio alla salute’ has monitored children in elementary schools throughout Italy since 2008. The latest report (Nardone et al. 2016) shows that these rates, at the national level, BOX 1. A DECREASE OF VACCINATION COVERAGE IS went down from 23% in 2008 to 20.9% for overweight, and from THE MAIN CAUSE OF A 2016–17 MEASLES OUTBREAK 12% to 9.8% for obesity among children aged 8–9. The trend of the prevalence of overweight is almost stable, with a slight decrease To meet the target of 95% vaccination coverage set by WHO in 2014 and 2016 with respect to the previous rounds; the guidelines, a National Vaccination Plan was approved in prevalence of obesity shows, instead, a steadily decreasing trend. 2012, stressing the right to vaccination, which is compulsory However, profound regional differences still remain, with southern and included in the benefits package. Although vaccination regions such as , and showing rates of coverage rates were mostly above the 95% target around overweight and obesity above 40%, while northern regions remain the year 2012, the recent trend is downward, with rates for below 25%. The Okkio report identifies large regional differences specific individual vaccines (DTP3, MCV, HepB3 ) down by 3 to in the availability of gyms in schools, initiatives for the promotion 5 percentage points in 2015. of healthier eating habits, and the percentage of schools that offer lunch, which is generally thought to result in healthier meals (below The reduction in vaccination led to a worrisome measles 50% in the south compared to 90% in the north). cases outbreak in 2016 and 2017, with a total of 865 cases in 2016 and 2 851 cases up to June 2017 (ECDC, 2017). Of the cases reported in 2017, 89% of people (mainly children) Antimicrobial resistance is a major threat to were not vaccinated, and 6% had received only the first dose population health, the health system and the of the vaccine (thereby increasing the likelihood of economy contagion compared to those who received Italy is particularly exposed to antimicrobial resistance (AMR), as it both doses). reports some of the highest levels of resistance in the EU for most As a response to this reduction in pathogens under surveillance by the European Centre for Disease vaccination coverage, 12 vaccines for Prevention and Control (ECDC, 2017). In 2014, Italy introduced children attending school were made a four-year national prevention plan for AMR based on a One- mandatory in May 2017. Health approach (i.e. a cross-sectoral approach to health hazards based on the idea that the health of , animals and ecosystems is interconnected). The current plan relies mainly on regions to implement monitoring systems, conservation and prevention strategies, and educational campaigns to promote the appropriate use of antibiotics. A new integrated plan – including many of the priorities highlighted in the WHO global plan for AMR – is currently being developed and should be launched in 2018. Italy is also engaged in the fight against AMR through its participation in international initiatives such as the Global Health Security Agenda, which aims to coordinate efforts at the global level to establish comprehensive AMR national plans, strengthen surveillance systems and promote antibiotic stewardship.

STATE OF HEALTH IN THE EU: COUNTRY HEALTH PROFILE 2017 – ITALY 12 . Performance of the health system

Italy 5.2 ACCESSIBILITY Figure 11. Italians’ unmet needs for medical care are among the highest in the EU, particularly for Despite universal coverage, a relatively high the poorest share of people reports unmet needs for High income Total population Low income medical care Estonia Greece The Italian National Health Service covers all citizens and foreign Romania residents, making the health system theoretically universal in terms Latvia of population coverage. It also gives access to basic services – such Poland as emergency care – to people without a residence permit without the Italy need for registration within the national health system. Other health Bulgaria care services for persons without a residence permit are increasingly Finland covered by nongovernmental organisations, but the costs outside of EU basic services are covered mainly through out-of-pocket payments. Portugal The market for voluntary health insurance is quite limited (0.9% Lithuania of total health expenditure in 2012). Voluntary health insurance is Ireland taken either as complementary insurance to reduce copayments, or United Kingdom as supplementary insurance to cover services such as dental care Hungary (which are partially outside the benefits basket) or to obtain access Belgium to intra-moenia8 services that guarantee faster treatment. In recent Slovak Republic Croatia years, governmental measures in the form of financial incentives (tax Cyprus exemptions) were introduced to enhance complementary insurance. Denmark France Despite full coverage for basic medical services, 7% of Italians Sweden reported some unmet needs for medical care in 2015 either for Luxembourg financial reasons, geographic reasons (having to travel too far) or Czech Republic waiting times. This is a higher proportion than the EU average (less Malta than 4%) and has grown in recent years. The proportion of people in Spain the lowest income group reporting some unmet needs for medical Germany care is particularly high (over 15.0% in 2015), compared to less Netherlands than 1.5% among people in the highest income group (Figure 11). Slovenia Most of the unmet medical needs are attributable to care being too Austria expensive, with waiting lists and geographic barriers for 0 10 20 a relatively small share. % reporting unmet medical need, 2015

Note: The data refer to unmet needs for a medical examination or treatment due to National studies have found a substantial amount of inequity costs, distance to travel or waiting times. Caution is required in comparing the data across countries as there are some variations in the survey instrument used. in health service use by socioeconomic status, with a significant Source: Eurostat Database, based on EU-SILC (data refer to 2015). amount of pro-rich inequity in specialist care, diagnostic services and basic medical tests, and pro-poor inequity in the use of primary Out-of-pocket spending increased after the care (Glorioso and Subramanian, 2014). Disparities in the use of economic crisis specialist care, diagnostic services and basic medical tests are largely connected to higher health literacy of the well-off (affecting Some 23% of health expenditure in Italy is paid out of pocket, the utilisation rates of preventive services and screening), flat-rate compared to the EU average of 15% (Figure 12). While primary copayments (limiting access to mainly specialist outpatient care for and hospital inpatient care are free at the point of service, flat low-income people) and low-quality services and long waiting lists copayments are levied on outpatient specialist visits (with a GP (particularly in the southern regions) that lead citizens to turn to referral, otherwise the full cost is paid), on diagnostic procedures, private health care, with ability to pay for those services positively and on medicines with full or partial reimbursement (within national associated with socioeconomic status. limits).

8. Public physicians who see private patients in public hospitals.

STATE OF HEALTH IN THE EU: COUNTRY HEALTH PROFILE 2017 – ITALY Performance of the health system . 13

Figure 12. More than one-fifth of health expenditure Italy BOX 2. THE NEW BENEFIT PACKAGE RATIONALISES is paid directly by AND EXPANDS THE LIST OF AVAILABLE HEALTH Italy SERVICES 1% 1% In 2016, the government approved a revised list of health services guaranteed to all Italian residents. When the first Essential Levels of Care were published in 2001, 23% the legislation only provided a general description of the sublevels of care that regions had to provide. In contrast, the new benefits package was developed on the basis of current 75% epidemiological and demographic needs and defines in detail the health services available to the population through public resources. Expanded benefits include: additional ambulatory specialist services, with particular emphasis on clinical Public/Compulsary effectiveness; new vaccinations and neonatal screenings; health insurance and new measures of innovative technologies, such as EU Out-of-pocket prostheses, to replace old procedures. Moreover, there is an 1% Voluntary health expanded list of chronic diseases for which services are fully 5% insurance covered by the National Health Service. Other 15%

demographic factors – do not match the resources required to fund the expanded benefit package. In accordance with the regulations of the Deficit Budget Plans, regions that do not consistently reach the 79% funding level required to fund the Essential Levels of Care will have to individually provide the additional funds to match the budget required to serve their population. Depending on the extent to which additional funds are available, interregional differences in access to the defined benefit package may persist and increase.

Source: OECD Health Statistics, Eurostat Database (data refer to 2015). 5.3 RESILIENCE Increasing copayment for medicines has become a frequently used policy tool to contain public spending in many regions and to reach A recentralisation process is underway better appropriateness in prescription. The majority of regions In 2001, Italy introduced a major decentralisation of fiscal, financial have implemented or increased different levels of copayments on and managerial responsibilities to regions. In particular, financial pharmaceuticals. Some regions have also implemented user fees transfers from the central government to regions were replaced for the inappropriate use of emergency services. Nevertheless, by regional taxes on and by a national solidarity some groups are exempted from these user fees, such as children fund financed by value-added taxes. However, several regions under the age of 6 and people over the age of 65, low-income experienced financial and service shortfalls, mainly due to weak groups, pregnant women, people with severe disabilities and people managerial capacity and lower productivity, which in turn also with many different medical conditions. affected perceived quality of care (Fattore, Petrarca, and Torbika 2014), leading to calls for (re)centralisation of the system. As a Interregional differences in the ability to consequence, half of the regions reported substantial deficits in the provide services comprised in the benefit health sector. Also following the 2009 economic crisis, the central government imposed an obligation to adopt regional recovery plans package may persist in regions with the largest deficits Piani( di Rientro), which have In 2016, the depth of coverage was revised and expanded (see Box 2). proven to be effective in reducing deficits.

Concerns are growing regarding individual regions’ ability to provide the services that the benefit package defines at the national level. Overall, the resources allocated to regions – mainly on the basis of

STATE OF HEALTH IN THE EU: COUNTRY HEALTH PROFILE 2017 – ITALY 14 . Performance of the health system

Italy Figure 13. Southern regions spend less on health addition, public spending on long-term care is projected to rise to compared to the national average 2.7% of GDP in 2060, reflecting the greater long-term care needs of ageing populations (European Commission and European Policy Campania Public (per capita) Committee, 2015). Calabria Private (per ) The focus on care integration and Puglia coordination is increasing The Balduzzi Decree, adopted in 2012, promoted the formation of voluntary group practices in primary care: while GPs still

Basilicata primarily work in solo practice, the evolution is towards group practice and team-working models to better address patients with complex needs. More recently, the 2014 Pact for Health went a step further towards care integration, requiring regions to establish ‘primary care complex units’ comprising GPs, specialists,

Lombardia nurses and social workers. This new organisational aims at improving continuity of care while reducing the inappropriate use of emergency services. -Venezia Giulia Toscana Improving the efficiency of the hospital Sardegna sector is necessary and within reach - As in many other EU countries, the number of hospital beds per Valle d’ capita in Italy has come down since 2000 (see Section 4). The number of beds – curative, rehabilitative and long-term care – per - Molise 1 000 population was 3.2 in 2015, which is much lower than the EU average of 5.1. However, large regional differences arise, with P.A. southern regions reporting a lower capacity (Figure 14). P.A.

-60 -40 -20 0 20 40 60 80 In contrast with other EU countries, the average length of stay in Difference to country average (%) hospitals has not reduced since 2000 – it has remained constant

Source: Ministero dell’Economia e delle Finanze and Istat (data refer to 2016). at around eight days (equal to the EU average). The average bed occupancy rate for hospitals in 2015 was 79%, also in line with the Providing services to an ageing population EU average. poses a threat to financial sustainability Generics only constitute a small share of Private health expenditure per household in richer regions – i.e. the autonomous (P.A.) of Bolzano, and Valle d’Aosta prescribed drugs in Italy – is two times that of poorer regions – Campania and Calabria The Spending Review of 2012, apart from including measures such (Figure 13). Southern poorer regions also report lower public health as the reduction of hospital bed ratios and reduced public financing spending, even if the variation across regions is lower than that of for the National Health System, made a further step to promote private spending.9 GPs’ prescription of generics by requiring them to explicitly state the active ingredients on their prescription, in order to facilitate With 22% of the population aged 65 and over in 2015, Italy has substitution. Despite this, the market penetration of generics in the oldest population in Europe. In this context, and under a set Italy is still relatively low compared to other European countries: of assumptions regarding the health of the population and 11% of pharmaceutical expenditure in value and 19% in volume economic growth, Italy’s public spending on health care as a share in 2015. In this case as well, large regional differences exist in how of GDP is projected to rise modestly to 6.7% of GDP in 2060. In generics are prescribed and consumed. However, the cause of these regional differences seems to be less rooted in policy variation across regions, and more in cultural preferences and local health 9. This variation is even lower if financial compensation for the interregional mobility of people to seek care is taken into account. authorities’ monitoring systems.

STATE OF HEALTH IN THE EU: COUNTRY HEALTH PROFILE 2017 – ITALY Performance of the health system . 15

Figure 14. Southern regions have lower hospital capacity Italy

Number of beds per 100 000 inhabitants 400 Curative Rehabilitive Long-term care 350

300

250

200

150

100

50

0 Italy Sicily Lazio Puglia Giulia Molise Liguria Veneto Marche Umbria Abruzzo Calabria Toscana Piemonte Sardegna Campania P.A. Trento Lombardia P.A. Bolzano Valle d’Aosta Friuli-Venezia Emilia-Romagna Source: Eurostat Database (data refer to 2015).

Preparing for the future, Italy is training more Stronger efforts to adopt new technologies nurses and regulating the status of paid and improve performance measurement are carers being made The workforce witnessed a freeze in recruitment of health In Italy, the National Committee for Medical Devices and the Agency professionals in the public sector following the 2008 economic for Regional Health Services contribute to promoting the adoption crisis. As already noted, the Italian health workforce is characterised of new cost-effective technologies (also linked to Health Technology by a relatively high number of doctors and a low number of nurses. Assessment – HTA). Additionally, some regions established their In response to this imbalance, the number of students admitted own agencies to monitor quality of care, carry out comparative to and graduating from nurse graduating programmes increased effectiveness analyses, and give scientific support to regional health substantially over the past 15 years, and improvements were made departments. in their curriculum. While the number of medical graduates has stayed relatively constant at around 6 500 per year, the number By strengthening eHealth and health information infrastructure of graduates more than quadrupled, from about 3 100 in in recent years, Italy increased its focus on performance 2000 to over 13 000 in 2014. The challenge now will be to create measurement. Following the of the regional recovery enough positions to absorb these growing numbers of graduates, plans, the government moved towards a better monitoring of given hiring freezes in recent times, to achieve a better balance hospital performance to ensure that the Essential Levels of Care between nurses and doctors. are being delivered to the population. Public providers are obliged by law to report different performance indicators, such as waiting While reliance on foreign nurses is low (about 5% of the total in times and quality measures, as part of a ‘health services chart’ 2015), demand for foreigners to provide care to elderly people published nationally. On accreditation grounds, these reporting at home (the so-called badanti, or paid carers) is very high. In practices were adopted by private providers as well, enabling the 2015, the demand for foreign informal carers was estimated to public and government to closely monitor and assess the quality of be around three times as high as the demand for formally trained services delivered to the population. nurses to provide home care. With the ageing population, this demand is expected to increase further. As most informal carers initially enter without a residence permit, the government has taken steps to ensure the regulation of their status and eased the entry requirements for nurse training.

STATE OF HEALTH IN THE EU: COUNTRY HEALTH PROFILE 2017 – ITALY Italy STATE OFHEALTH INTHE EU: COUNTRY HEALTH PROFILE2017 –ITALY l l l l l 16

. introduction of the Deficit Reduction Plans. Plans. Reduction Deficit of the introduction following the regions most in were implemented services emergency of use hospital for inappropriate and for medicines copayments Increased for health. funding public in crisis areduction to led economic 2008 of the aftermath the in measures of cost-containment A series children. among obesity and of overweight 40% above rates show Molise and Campania Calabria, as such regions obesity, southern and of overweight prevalence the reduce to government Italian by the taken steps Despite deaths. smoking-related other and cancer lung from deaths reduce to as so adults, and adolescents among rates smoking reduce to needed are efforts Yet further low drinking. of levels binge and consumption lowalcohol generally EU, reflecting the in lowest the is among deaths of alcohol-related number The diseases. cardiovascular from mortality in reductions steady low to and mainly due countries, EU in lowest the among are Italy in rates mortality Amenable gains. life expectancy and health population to contributions important made has system health Italian The capacity of poorer regions to fund access to these these to access fund to regions of poorer capacity the regarding concerns raises of funds allocation The country. the in residents all to provided be must which package, benefits generous more this implement to ability financial regions’ regarding concerns 2016, are there but in expanded and revised was package benefits health the years, recent in recovery economic the Following arrangements. cost-sharing from exempted nevertheless are groups Various vulnerable care. to access in inequality of degree asignificant suggesting high, is particularly costs to due care for medical needs unmet reporting group income lowest the in of people proportion The Key findings 6 Keyfindings l l

and rising out of pocket payments. of pocket out rising and needs unmet rates of possiblyto growing leading deficits), (or running taxes regional increasing without services tackle the increasing demand for long-term care. for long-term demand increasing the tackle to attempt elderly, an in for the care regulated is being home providing of carers share largest the constitute who workers, care role of personal The graduates. new these forall system of health the in positions suitable find to be will now challenge The 15 years. past over the quadrupled schools nursing from graduates of new number annual the countries, EU other most to compared doctors to by alow of ratio nurses is characterised country the While resources. use of efficient amore achieve to and population, ageing of an needs care long-term and health growing the tackle to attempt an in regulated being are carers paid and trained being are nurses More facilitate to substitution. drugs of prescribed ingredients active the state explicitly to GPs by requiring of generics prescription the promote policies Recent drugs. of overall prescribed volume of the share asmall constitute still generics spending, pharmaceutical in efficiency to improve efforts policy Despite

Health in Italy . c

Key sources Italy

Ferré, F. et al. (2014), “Italy: Health System Review”, Health OECD/EU (2016), Health at a Glance: Europe 2016 – State of Systems in Transition, Vol. 16(4), pp. 1-168. Health in the EU Cycle, OECD Publishing, , http://dx.doi.org/10.1787/9789264265592-en.

References

ECDC (2017), “Antimicrobial Resistance Surveillance in Europe IHME (2016), “Global Health Data Exchange”, Institute for 2015”, Annual Report of the European Antimicrobial Health Metrics and Evaluation, available at Resistance Surveillance Network (EARS-Net). http://ghdx.healthdata.org/gbd-results-tool on 8 February 2017. ECDC (2016), “Hepatitis C”, Annual Epidemiological Report for 2015. Ministry of Health (2011), “Sistema di valutazione e monitoraggio della qualità dell’assistenza e delle European Commission (DG ECFIN) and Economic Policy performance dei sistemi sanitari”, Relazione sullo Committee (AWG) (2015), “The 2015 Ageing Report – stato sanitario del 2009-2010, Roma, available Economic and budgetary projections for the 28 EU Member at www.rssp.salute.gov.it/rssp/paginaParagrafoRssp. States (2013-2060)”, European Economy 3, , May. jsp?sezione=risposte&capitolo=valutazione&id=2677.

Fattore, G., G. Petrarca and A. Torbika (2014), “Traveling for Nardone, P. et al. (2016), “Il sistema di sorveglianza OKkio Care: Inter-regional Mobility for Aortic Valve Substitution in alla Salute. Risultati 2014”, Italy”, Health Policy, Vol. 117, pp. 90-97. http://www.epicentro.iss.it/okkioallasalute/.

Glorioso, V. and S.V. Subramanian (2014), “Equity in Access to OASI (2016), “Strutture e attività SSN”, Rapporto OASI, Cergas Health Care Services in Italy”, Health Services Research, Vol. Università Bocconi. 49(3), pp. 950-970. OECD (2014), OECD Reviews of Health Care Quality: Italy 2014: Raising Standards, OECD Publishing, Paris, http://dx.doi.org/10.1787/9789264225428-en.

Country abbreviations Austria AT Denmark DK Hungary HU Malta MT Slovenia SI Belgium BE Estonia EE Ireland IE Netherlands NL Spain ES Bulgaria BG Finland FI Italy IT Poland PL Sweden SE Croatia HR France FR Latvia LV Portugal PT United Kingdom UK Cyprus CY Germany DE Lithuania LT Romania RO Czech Republic CZ Greece EL Luxembourg LU Slovak Republic SK

STATE OF HEALTH IN THE EU: COUNTRY HEALTH PROFILE 2017 – ITALY State of Health in the EU Country Health Profile 2017

The Country Health Profiles are an important step in the Each Country Health Profile provides a synthesis of: European Commission’s two-year State of Health in the EU l  health status cycle and are the result of joint work between the Organisation l  the determinants of health, focussing on behavioural risk for Economic Co-operation and Development (OECD) and the factors European Observatory on Health Systems and Policies. This l  the organisation of the health system series was co-ordinated by the Commission and produced with l  the effectiveness, accessibility and resilience of the health the financial assistance of the European Union. system

The concise, policy relevant profiles are based on a transparent, This is the first series of biennial country profiles, published in consistent methodology, using both quantitative and qualitative 2017. The Commission is complementing the key data, yet flexibly adapted to the context of each EU Member findings of these country profiles with a Companion Report. State. The aim is to create a means for mutual learning and voluntary exchange that supports the efforts of Member States For more information see: ec..eu/health/state in their evidence-based policy making.

Please cite this publication as:

OECD/European Observatory on Health Systems and Policies (2017), Italy: Country Health Profile 2017, State of Health in the EU, OECD Publishing, Paris/European Observatory on Health Systems and Policies, Brussels. http://dx.doi.org/10.1787/9789264283428-en

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