State of Health in the EU Italy IT Country Health Profile 2019 The Country Health Profile series Contents
The State of Health in the EU’s Country Health Profiles 1. HIGHLIGHTS 3 provide a concise and policy-relevant overview of 2. HEALTH IN ITALY 4 health and health systems in the EU/European Economic 3. RISK FACTORS 7 Area. They emphasise the particular characteristics and challenges in each country against a backdrop of cross- 4. THE HEALTH SYSTEM 8 country comparisons. The aim is to support policymakers 5. ASSESSMENT OF THE HEALTH SYSTEM 11 and influencers with a means for mutual learning and 5.1. Effectiveness 11 voluntary exchange. 5.2. Accessibility 15 The profiles are the joint work of the OECD and the 5.3. Resilience 18 European Observatory on Health Systems and Policies, 6. KEY FINDINGS 22 in cooperation with the European Commission. The team is grateful for the valuable comments and suggestions provided by the Health Systems and Policy Monitor network, the OECD Health Committee and the EU Expert Group on Health Information.
Data and information sources The calculated EU averages are weighted averages of the 28 Member States unless otherwise noted. These EU The data and information in the Country Health Profiles averages do not include Iceland and Norway. are based mainly on national official statistics provided to Eurostat and the OECD, which were validated to This profile was completed in August 2019, based on ensure the highest standards of data comparability. data available in July 2019. The sources and methods underlying these data are To download the Excel spreadsheet matching all the available in the Eurostat Database and the OECD health tables and graphs in this profile, just type the following database. Some additional data also come from the URL into your Internet browser: http://www.oecd.org/ Institute for Health Metrics and Evaluation (IHME), the health/Country-Health-Profiles-2019-Italy.xls European Centre for Disease Prevention and Control (ECDC), the Health Behaviour in School-Aged Children (HBSC) surveys and the World Health Organization (WHO), as well as other national sources.
Demographic and socioeconomic context in Italy, 2017
Demographic factors Italy EU Population size (mid-year estimates) 60 537 000 511 876 000 Share of population over age 65 (%) 22.3 19.4 Fertility rate¹ 1.3 1.6 Socioeconomic factors GDP per capita (EUR PPP²) 28 900 30 000 Relative poverty rate³ (%) 20.3 16.9 Unemployment rate (%) 11.2 7.6
1. Number of children born per woman aged 15-49. 2. Purchasing power parity (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 60 % of median equivalised disposable income. Source: Eurostat Database.
Disclaimer: The opinions expressed and arguments employed herein are solely those of the authors and do not necessarily reflect the official views of the OECD or of its member countries, or of the European Observatory on Health Systems and Policies or any of its Partners. The views expressed herein can in no way be taken to reflect the official opinion of the European Union.
This document, as well as any data and map included herein, are without prejudice to the status of or sovereignty over any territory, to the delimitation of international frontiers and boundaries and to the name of any territory, city or area.
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© OECD and World Health Organization (acting as the host organisation for, and secretariat of, the European Observatory on Health Systems and Policies) 2019
2 State of Health in the EU · Italy · Country Health Profile 2019 80 85 75 Life expectancy at birth,years EUR 2000 causes ofmortalityintheEU. rates of preventable andtreatable deaths, with oneofthelowest effective atavoiding premature Italy’s healthsystemisrelatively Effectiveness Per capita spending(EURPPP) % of adults share ofthe population living with chronic diseasesandreducing disparitiesinaccesstocare. regions. The mainchallenges facing thehealthsystemrelate toimproving coordination ofcare forthe growing providing good accesstohigh-qualitycare atarelatively low cost, althoughthere are significant variations across by gender andsocioeconomicstatus. The Italianhealthcare systemis generally efficientand performs in well Italy enjoys thesecondhighestlifeexpectancy inEurope, althoughsizeableinequalities persist across regions and 1 per 100000population, 2016 Age-standardised mortality rate EUR 3000 Prevent ble EUR 1000 Obest Bne drnn Smon IT IT IT IT 799 mort l t mort l t 773 Tre t ble Highlights 2000 Bne drnn EU EU EU EU 2005 Smon 17 Obest 21 22 67 93 110 157 2011 7
% 1 % 2017 809 831 2 0 % 2017 % reporting unmet medical needs, 2017 EU IT mainly through out-of-pocket payments. three-quarters ofhealthspending is publicly funded, with therest paid of GDPin2017, one percentage point below theEUaverage of9.8%. Nearly countries. As ashare oftheeconomy, healthspending accountedfor8.8% increase again inrecent years, but ataslower rate thaninmostEU below theEUaverage ofEUR2884. Healthspending hasstartedto Health spending per capita inItaly was EUR2483in2017, about15% Health system episodic heavy drinking ismuch lower thaninmostEUcountries. EU average. Onamore positive note, the proportion ofadults who report of 15-year-olds being overweight orobesein2013-14, ashare close tothe adolescents are alsoanimportant public healthissue, with aboutone-fifth below theEUaverage (15%). Excess weight problems among children and among adultsincreased from 9%in2003to112017butremains smoked daily in2017, slightly more thantheEUaverage (19%). Obesity Smoking rates inItaly have decreased since2000, butoneinfive adultsstill Risk factors years more thanthoseliving intheleastaffluent inthesouth.regions educated, and people inthemostaffluent inthenorthliveregions over three the leasteducatedItalianmenonaverage live 4.5 years lessthanthemost Important disparities alsoexistby socioeconomicstatusandacross regions: narrowed, butonaverage live Italianmenstill four years lessthan women. in theEUafterSpain. Since2000, the gender gap inlifeexpectancy has Life expectancy atbirthinItaly reached 83.1 years in2017, thesecondhighest Health status Accessibility services. greater barrierstoaccessing some in someregions experience low-income groups andresidents Italy are generally low, although Unmet needsformedicalcare in 0% Hh ncome %01 Countr EU EU Countr %01 EU Countr State of Healthin the EU ·Italy ·Country Health Profile 2019 All 3% Low ncome 6% outside hospitals. the provision ofchronic care service delivery modelstowards through furthertransformation of requiring increased efficiency care systemsinthe years ahead, health andlong-term exert will pressure on population ageing Member States, As inmany other Resilience
3
ITALY ITALY 2 Health in Italy
Life expectancy at birth in Italy is of Italians increased by 3.2 years, a slightly slower the second highest in the EU gain than in the EU as a whole (3.6 years).
At 83.1 years in 2017, Italy continues to enjoy the The gender gap in life expectancy is smaller than the second highest life expectancy at birth in the EU after EU average. While Italian women still live more than Spain and more than two years above the EU average four years longer than men, this gap has narrowed (Figure 1). Between 2000 and 2017, the life expectancy by 1.5 years as men’s life expectancy increased more rapidly than that of women between 2000 and 2017.
Figure 1. Italians enjoy the second highest life expectancy in the EU
Ye rs 2017 2000 90 –
Gender gap: Italy: 4.4 years 85 – 834
831 EU: 5.2 years 827 827 826 825 824 822 822 821 818 817 817 816 816 814 813 812 811 811 809
80 – 791 784 78 7 78 773 76 758 753 749 748 75 –
70 –
65 – EU Sp n It l Fr nce M lt CprusIrel nd Greece Pol nd L tv Norw Icel ndSweden Austr F nl ndBel um Czech Eston Cro t Bul r Portu l Sloven Germ nDenm r Slov Hun rL thu n Rom n Luxembour Netherl nds Un ted n dom Source: Eurostat Database.
Inequalities in life expectancy are less Figure 2. The education gap in life expectancy is pronounced than in other EU countries 4.5 years for men and about 3 years for women
Although less severe than in most other EU countries, inequalities in life expectancy by socioeconomic status remain non-negligible in Italy. As shown in Figure 2, 30-year-old men with lower levels of 57 6 education live on average 4.5 years less than those 54 7 ers 54 1 ers ers 49 6 with the highest level of education. This education ers gap in longevity is smaller among women, at about three years. These gaps can be explained at least partly by differences in exposure to various risk Lower Higher Lower Higher factors and unhealthy lifestyles, including higher educated educated educated educated women women men men smoking rates and poorer nutritional habits among men and women with lower levels of education. Education gap in life expectancy at age 30: Italy: 2.9 years Italy: 4.5 years Regional inequalities in life expectancy also exist but EU21: 4.1 years EU21: 7.6 years are less pronounced than those by education level. In 2017, the region with the highest life expectancy at Note: Data refer to life expectancy at age 30. High education is defined as people who have completed tertiary education (ISCED 5-8), whereas birth was the northern region of Trentino-Alto-Adige, low education is defined as people who have not completed secondary where citizens could expect to live over three years education (ISCED 0-2). longer than in the southern region of Campania, Source: Eurostat Database (data refer to 2016). which had the lowest.
4 State of Health in the EU · Italy · Country Health Profile 2019 -100 100 % c age with somehealthissuesanddisabilities. women live a greater proportion oftheirlives inold in thenumber ofhealthy life years becauseItalian years infavour of women, butthere isno gender gap gender gap inlifeexpectancy atage 65isaboutthree 65 with somehealthissuesanddisabilities. The more thanhalfoftheseadditional years oflifeafter However, asinothercountries, Italiansspendslightly 21 years, one year above theEUaverage (Figure 4). In 2017, lifeexpectancy atage 65reached nearly increase toaround oneinthree people by 2050. only oneineight1980;thisshare is projected to in five Italians was aged 65 years and over, upfrom population aged 65andover. In2017, more thanone toasteadycontributed riseintheshare ofthe low rates fertility over thelasttwo decadeshave Sustained gains inlifeexpectancy combined with some chronic diseasesanddisabilities Many years oflifeafterage 65arelived with Source: Eurostat Database. in diagnostic anddeath registration practices. Note: Thesize of thebubbles isproportional to themortality rates in2016. Theincrease inmortality rates from Alzheimer’s disease islargely dueto changes Figure 3. Ischaemic disease, heart stroke andlungcancer are still theleading causes of death death inItaly in2016 (Figure 3). Lung cancerand although they remained thetwo leading causesof rates from ischaemic heartdiseaseandstroke, been driven by substantialreductions inmortality The increase inlifeexpectancy since2000hasmainly main causeofdeath inItaly Cardiovascular diseasesremain the -50 50 0 hn Pneumon e 2000-16(orner 10 Pncretc cncer Br est cncer Colorectl cncer est Alzhemer’s dsese
20 er)
Dbetes
Chronc obstructvepulmonr dsese 40 State of Healthin the EU ·Italy ·Country Health Profile 2019 50 and changes indeathregistration practices. this riseisduelargely toimprovements indiagnosis disease have increased significantly inItaly, although At thesametime, mortalityrates from Alzheimer’s decreased by about15%since2000. death from cancer, butmortalityrates have also colorectal cancer are themostfrequent causesof symptoms, ahigher proportion thantheEUaverage. aged 65 years andmore reported somedepression long-term care assistance. About fourinten people such asdressing andeating, which may require some limitationsinbasicactivities ofdaily living, one insixItaliansaged 65andover reported in2017 able tocontinue tolive independently inold age, but which islower thantheEUaverage. Most people are reported having atleastonechronic diseasein2017, Slightly lessthanhalfofItaliansaged 65andover Lun cncer Ae-stndrdsed mortlt rteper100000populton,2016 60 70 Str oe 80 Isc hemc hertdsese
100 5
ITALY Figure 4. About half of Italians report one or more chronic diseases after age 65
ITALY Lfe expectnc t e 65 It l EU
96 209 199 10 99 ers 113 ers
Ye rs wthout Ye rs wth ds blt ds blt
% of people ed 65+ reportn chronc dseses % of people ed 65+ reportn lmttons n ctvtes of dl lvn (ADL) It l EU25 It l EU25
17% 20% 18% 18%
46% 51% 32% 34% 82% 82%
No chronc One chronc At le st two No lmt ton At le st one dse se dse se chronc dse ses n ADL lmt ton n ADL
% of people ed 65+ reportn depresson s mptoms3 It l EU11
41% 29 %
Note: 1. Chronic diseases include heart attack, stroke, diabetes, Parkinson disease, Alzheimer’s disease and rheumatoid arthritis or osteoarthritis. 2. Basic activities of daily living include dressing, walking across a room, bathing or showering, eating, getting in or out of bed and using the toilet. 3. People are considered to have depression symptoms if they report more than three depression symptoms (out of 12 possible variables). Sources: Eurostat Database for life expectancy and healthy life years (data refer to 2017); SHARE survey for other indicators (data refer to 2017).
6 State of Health in the EU · Italy · Country Health Profile 2019 while theywhile have dropped inmostotherEUcountries. adolescents have between notfallen 1995and2015, rate intheEU(Figure 6). Smoking rates among Italian at leastoccasionally inthe past month, the highest 16-year-old boys and reportedgirls they hadsmoked very high. In2015, more thanone-third of15-and Smoking rates among teenagers inItaly remain in mostEUcountries. slightly over the past decade, itremains higherthan 15 %of women. this While proportion hasdecreased four reporting smoking daily in2017, compared with issue inItaly, particularly among men, with onein Tobacco consumption remains amajor public health healthissue public Smoking remainsanimportant Source: IHME(2018), GlobalHealth Data Exchange (estimates refer to 2017). sweetened beverages andsaltconsumption. death can beattributed to more thanoneriskfactor. Dietary risksinclude14components suchaslow fruitandvegetable consumption andhighsugar- Note: Theoverall numberof deaths related to these riskfactors (210 000) islower thanthesumof each onetaken individually(231 000), because thesame Figure 5. Aboutone-third of alldeaths canbeattributed to modifiableriskfactors average. (Figure 5;IHME, 2018). This ismuch lower thantheEU alcohol consumption andlow physical activity risk factors, including dietaryrisks, tobaccosmoking, in Italy in2017could tobehavioural beattributed Estimates suggestthataboutone-third deaths ofall deathsone-third ofall inItaly Behavioural riskfactorsaccount for 3 EU 18% It l 16% D etr r ss Riskfactors
EU 17% It l 14% Tobcco State of Healthin the EU ·Italy ·Country Health Profile 2019 below theEUaverage except forlow physical activity. (18 000)tolow physical activity. thesesharesAll are could toalcoholconsumption, beattributed and3% deaths.90 000)ofall About 4%(26000)ofdeaths smoking) was responsible foranestimated14%(over consumption (including direct andsecond-hand intake andhighsugarsaltconsumption). Tobacco to dietaryrisks(including low fruitand vegetable About 16%(98000)ofdeathsin2017 were related than inmostEUcountries. according to anationalsurvey, but itremains lower past 15 years, upfrom 9%in2003to11%2017 Obesity among adultshasincreased slightly over the adults isalsoamong thelowest intheEU. countries. The level of physical activity among Italian exercise in2013-14, thelowest rate across EU boys reported doing atleastmoderate daily physical Only 5%of15-year-old and11%of15-year-oldgirls are atleast partly linked tolow physical activity. High rates ofoverweight andobesity among children slightly from etal., 35%in2008(Spinelli 2017). overweight orobese in2016, butthisrate was down in three children (31%)aged 8-9 years was either reported even higherrates, showing thatnearly one national survey focusing on primary school children Europe-wide HBSCsurvey. Another more recent overweight orobesein2013-2014, according tothe Nearly oneinfive 15-year-olds inItaly (18%) was among children andadolescents Overweight andobesityrates arehigh EU 3% It l 3% Low phs clct v t EU 6% It l 4% Alcohol 7
ITALY Figure 6. Many risk factors among children are more prevalent than in other EU countries ITALY Smon (chldren)
Ve etble consumpton (dults) 6 Smon (dults)
Frut consumpton (dults) Bn e drnn (chldren)
Phscl ctvt (dults) Bn e drnn (dults)
Phscl ctvt (chldren) Overwe ht nd obest (chldren)
Obest (dults)
Note: The closer the dot is to the centre, the better the country performs compared to other EU countries. No country is in the white ‘target area’ as there is room for progress in all countries in all areas. Sources: OECD calculations based on ESPAD survey 2015Select and dotsHBSC +survey Effect 2013-14 > Trnsform for children scle indicators; 130% and EU-SILC 2017 and EHIS 2014 and OECD Health Statistics 2019 for adults indicators.
A greater proportion of Italian adults report the lowest in the EU. The proportion of adults who consuming at least one portion of fruit and vegetable report heavy episodic alcohol consumption (“binge per day than in most EU countries; nevertheless, drinking”1) is also much lower than in nearly all other 15 % reported in 2017 that they did not eat at least EU countries. one fruit each day and 20 % that they did not eat any vegetables. However, binge drinking among adolescents is quite widespread. In 2015, around one-third of 15-16- Alcohol consumption among adults is low, but year-old boys and girls reported at least one episode a third of adolescents engage in binge drinking of heavy alcohol drinking during the past month, a proportion close to the EU average. Alcohol consumption among adults in Italy has decreased by about 20 % since 2000 and is now among
4 The health system
Italy has a highly decentralised health organisation and delivery of health services through system providing universal coverage local health units and public and accredited private hospitals. The health service covers all citizens and The Italian health system is characterised by a legal foreign residents. Coverage is automatic and decentralised, regionally based national health service universal, and care is generally free for hospital and (NHS). The central government channels general tax medical services. Irregular immigrants have been revenues for publicly financed health care, defines entitled to access urgent and essential services since the benefit package (known as thelivelli essenziali 1998. di assistenza, ‘essential levels of care’) and exercises overall stewardship. Each region is responsible for the
1: Binge drinking is defined as consuming six or more alcoholic drinks on a single occasion for adults, and five or more alcoholic drinks for adolescents.
8 State of Health in the EU · Italy · Country Health Profile 2019 4 000 and Sicily) –fewer thanin2007. (Abruzzo, Apulia, Calabria, Campania, Lazio, Molise were undernationally supervisedrecovery plans recent years. In2017, only seven ofthe20regions managed tokeep theirhealthbudgetsbalancedin very tightexpenditure controls, mostregions have or running deficits(Box 1). Nevertheless, through health care services without increasing regional taxes performing regions to provide accesstohigh-quality raise of concernsabouttheability poorer orlower- and healthsystemefficiency levels across regions paid directly by patients. Different fiscalcapacities and individual incometaxesandco-payments complemented by revenues from regional business Italy’s NHSismainly fundedthrough general taxation, been reducedsubstantially The regions’healthcaredeficitshave Source: OECD Health Statistics 2019 (data refer to 2017). Figure 7. Italyspendsless onhealthcare thanmost other western European countries it startedtoincrease again atleastmoderately. health spending per capita 2013, until fell after which (Figure 7). Following theeconomiccrisisin2009, more than10% below theEUaverage ofEUR2884 2 483(adjustedfordifferences in purchasing power), capita terms, healthexpenditure amountedtoEUR a lower share thantheEUaverage of9.8%. In per In 2017, Italy spent8.8%ofitsGDPonhealthcare, than the EUaverage Health spending in Italy islower EUR PPPperc pt 2 000 5 000 3 000 1 000 Government &compulsor nsur nce 0 Norw
Germ n
Austr
Sweden Netherl nds
Denm r
LuxembourFr nce
Belum
Irel nd Volunt r schemes &household out-of-pocet p ments
Icel nd Unted ndom Fnl nd
State of Healthin the EU ·Italy ·Country Health Profile 2019 EU M lt
It l expenditure. a minorrole, covering only about2%oftotalhealth remaining expenses. Private healthinsurance plays are relatively high(24%), making upmostofthe direct out-of-pocket (OOP) payments by households basic benefit package covers a wide range ofservices, expenditure in2017(or 6.5%ofGDP). Although the Public spending accounted for74%ofhealth Autonomous Province of Bolzano). (Campania, Valle d’Aosta, Sardinia, Calabria andthe comply withthenational objectives andtargets package reported that in2017 five regions didnot for monitoring theprovision of thebenefit across regions. Thenational committee responsible have resulted indifferent levels of implementation lack of national guidelines andfinancialconstraints the tariffs paid for different services. However, the package also includedalong-overdue update of neonatal screening andassistive devices. The new diseases, new diagnostic services, new vaccines, include treatment for alist of rare andchronic a moderate expansion of thebenefit package to In January 2017, theItaliangovernment approved deliver new services but several regions donot have thecapacity to Box 1. Thebenefit package was expanded in2017, Sp n
Czech Autonomous Province of Bolzano). (Campania, Valle d’Aosta, Sardinia, Calabria andthe comply withthenational objectives andtargets package reported that in2017 five regions didnot for monitoring theprovision of thebenefit across regions. Thenational committee responsible have resulted indifferent levels of implementation lack of national guidelines andfinancialconstraints the tariffs paid for different services. However, the package also includedalong-overdue update of neonatal screening andassistive devices. Thenew diseases, new diagnostic services, new vaccines, include treatment for alist of rare andchronic a moderate expansion of thebenefit package to In January 2017, theItaliangovernment approved capacity to deliver new services in 2017, butseveral regions donot have the Box 1. Thebenefit package was expanded
Sloven
Portu l
Cprus
Greece
Slov
Lthu n
Eston
Pol nd
Hun r
Bul r
Cro t
L tv Sh re of GDP Rom n % of GDP 00 25 50 5 7 100 125 9
ITALY Regions can also choose to offer services beyond its own co-payment levels for pharmaceuticals, the benefit package list, but must finance these with various exemptions for some population
ITALY themselves. Significant inter-regional mobility of groups, meaning that co-payment levels are not patients is one indicator of inequalities in health homogeneous across the country. There are no annual service delivery across the country. The percentage of ceilings on co-payments, so these have the greatest patients treated in a different region than their home impact for heavy users of health services who are not region increased from 7 % in 2001 to about 8.5 % in eligible for exemptions. 2016. The proportion of patients in the south choosing to be treated in another region is almost twice as high The number of doctors is higher than the EU as in the north. average, while the number of nurses is lower
User fees are common across Italy, but rates While the total number of doctors per population in and exemptions vary between regions Italy is higher than the EU average (4.0 compared with 3.6 per 1 000 population in 2017), the number working Historically, OOP spending has made up a little more in public hospitals and as general practitioners than one-fifth of all health spending. However, over (GPs) is declining, and more than half of doctors are the last decade, the share has gradually increased, aged over 55, raising serious concerns about future reflecting rising cost-sharing requirements for shortages. many health services and pharmaceuticals in several regions (see Section 5.2). Co-payments are Italy employs fewer nurses than nearly all western required for diagnostic procedures, pharmaceuticals, European countries (with the exception of Spain), and specialist visits in outpatient settings and the number is substantially lower than the EU average unjustified (non-urgent) interventions in hospital (5.8 nurses per 1 000 population compared with 8.5 in emergency departments. Each region establishes the EU; Figure 8).
Figure 8. Compared to the EU average, Italy has a high number of doctors but fewer nurses
Prctcn nurses per 1 000 populton 20 Doctors Low Doctors H h Nurses H h Nurses H h 18 NO
16
FI IS 14 IE DE
12 LU BE NL SE SI D 10 FR EU EU ver e 85 MT 8 U HR LT HU RO EE CZ ES PT AT 6 IT PL S LV CY BG 4 EL
2 Doctors Low Doctors H h Nurses Low EU ver e 36 Nurses Low 0 2 25 3 35 4 45 5 55 6 65 Prctcn doctors per 1 000 populton
Note: In Portugal and Greece, data refer to all doctors licensed to practise, resulting in a large overestimation of the number of practising doctors (e.g. of around 30 % in Portugal). In Austria and Greece, the number of nurses is underestimated as it only includes those working in hospitals. Source: Eurostat Database (data refer to 2017 or the nearest year).
10 State of Health in the EU · Italy · Country Health Profile 2019 imposed ontobaccoretailers who sold cigarettes purchase age was raised to18 years, higherfines were young people were alsointroduced: theminimum In 2013, stricterrules ontobaccoaccessamong successive increases incigarette prices were enforced. and workplaces was implemented in2005, and (Box 2). A nationwide smoking banin public places policies that were implemented about adecadeago explained atleastin part by solid public health Italy’s low levels of preventable deathscanbe off with low preventable death rates healthpoliciesin Public the 2000sarepaying generally provided when thesediseasesoccur. than theEUaverage, becauseeffective treatments are and colorectal cancer, which are significantly lower mortality rates from ischaemic heartdisease, stroke These positive results are related torelatively low treating patients with life-threatening conditions. the Italianhealthsystemis generally effective in of thelowest intheEU2016, indicating that through healthcare interventions was alsoone The number ofdeathsdeemed potentially avoidable lower incidence ofthesehealth problems. because ofalower prevalence ofriskfactorsand diseases, which are all well below theEUaverages, cancer, accidental deaths, suicide andalcohol-related mortality rates from ischaemic heartdisease, lung This low rate of preventable mortalityreflects low mortality rate intheEUafterCyprus(Figure 9). 2016, Italy reports thesecondlowest preventable Following areduction ofover 10%between 2011and reflect thehealthsystem’s effectiveness Low rates ofpreventable and treatable mortality 5.1. 5 depending on perceived qualityand waiting time. care andspecialised ambulatoryservices, usually choose either public or private providers forhospital to secondarycare. UndertheNHS, patients can GPs and paediatricians actas gatekeepers foraccess providers, alongside private or public-private entities. Health servicesare mainly delivered by public key focusofhealthcareinnovation Improving careforchronic diseasesisa Assessment of thehealthsystem Effectiveness State of Healthin the EU ·Italy ·Country Health Profile 2019 was implemented. Inaddition, in2016, a new law and abanonsalesofelectronic cigarettes tominors ban was extendedtotheoutdoor premises ofschools intobacco installed vending machines, asmoking to minors, automaticage-detection systems were formal evaluation. in mostcasesthese havepilots notbeensubjectto the needsof patients with co-morbidities. However, combine healthandsocialcare, tobetterrespond to community-based centres andcasemanagement that health servicemodels, through multispecialty regions are piloting theimplementation ofdifferent Cronicità;della MinistryofHealth, 2016). A number of was launched inSeptember 2016(PianoNazionale designed toimprove thecoordination ofchronic care to meetemerging care needs, anationalinitiative Recognising thatnew typesofservicesare required contributed toreducingcontributed alcoholconsumption. alcohol purchasing age limitto18 years in 2012 have events introduced inthe2000sandincrease inthe driving regulations, salesrestrictions during mass In addition, alcoholcontrol policies such asdrink- specifically etal.,by urbanisation(Allamani 2014). sociodemographic andeconomicfactors, andmore recent decadescanbeexplainedlargely by various The remarkable reduction inalcoholconsumption in in theoutdoor premises ofhospitals. (in the presence of pregnant women andminors) cigarette packs andintroduced asmoking banincars regulated thecombinationofimages and warnings on 11
ITALY Figure 9. Italy has among the lowest rates of preventable and treatable mortality in the EU
ITALY Preventble cuses of mortlt Tretble cuses of mortlt
Cprus 100 Icelnd 62 Itl 110 Norw 62 Mlt 115 Frnce 63 Spn 118 Itl 67 Sweden 121 Spn 67 Norw 129 Sweden 68 Frnce 133 Netherlnds 69 Netherlnds 134 Luxembour 71 Irelnd 138 Cprus 71 Icelnd 139 Belum 71 Luxembour 140 Denmr 76 Portul 140 Fnlnd 77 Greece 141 Austr 78 Unted ndom 154 Sloven 80 Belum 155 Irelnd 80 Germn 158 Germn 87 Denmr 161 Mlt 87 Austr 161 Portul 89 EU 161 Unted ndom 90 Fnlnd 166 EU 93 Sloven 184 Greece 95 Czech 195 Czech 128 Polnd 218 Polnd 130 Crot 232 Crot 140 Bulr 232 Eston 143 Slov 244 Slov 168 Eston 262 Hunr 176 Romn 310 Bulr 194 Hunr 325 Ltv 203 Ltv 332 Lthun 206 Lthun 336 Romn 208 0 50 100 150 200 250 300 350 0 50 100 150 200 250 Ae-stndrdsed mortlt rtes per 100 000 populton Ae-stndrdsed mortlt rtes per 100 000 populton
Lun cncer Lver cncer Colorectl cncer Stroe Ischemc hert dseses Stomch cncer Ischemc hert dseses Dbetes Accdents (trnsport nd others) Others Brest cncer Others
Note: Preventable mortality is defined as death that can be mainly avoided through public health and primary prevention interventions. Mortality from treatable (or amenable) causes is defined as death that can be mainly avoided through health care interventions, including screening and treatment. Both indicators refer to premature mortality (under age 75). The data is based on the revised OECD/Eurostat lists. Source: Eurostat Database (data refer to 2016).
BoxBox 2. A2. national A national programme programme addresses addresses relevant relevant risk risk factorsa broader through social a multisectoral and environmental approach perspective factors through a multisectoral approach through intersectoral actions based on the ‘Health The ‘Gaining Health: Making Healthy Choices Easier’ inenvironmental All Policies’ perspectiveprinciples. through intersectoral (Guadagnare salute: rendere facili le scelte salutari) is actions based on the ‘Health in All Policies’ principles. Thea ‘Gaininglongstanding Health: national Making programme Healthy initially Choices approved Easier’ (Guadagnarein 2007 and salute: still implemented rendere facili today le sceltein cooperation salutari) Building on on this this longstanding longstanding programme, programme, in in is a longstanding national programme initially February 2019, the Ministers of Health and with the regions and autonomous provinces. Its February 2019, the Ministers of Health and Education approved in 2007 and still implemented today in adoptedEducation a newadopted set of a policy new set guidelines of policy to guidelinespromote to cooperationmain objective with is the to address,regions inand a coordinatedautonomous way, promote better nutrition, physical activity and other better nutrition, physical activity and other health- provinces.four key Itsmodifiable main objective risk factors is to to address, health across in a health-promotion activities in schools (Ministry of coordinatedthe population way, of four all ages:key modifiable poor nutrition, risk physicalfactors Health,promotion 2019). activities in schools (Ministry of Health, to inactivity,health across smoking the populationand alcohol consumption.of all ages: poor These 2019). nutrition,issues are physical addressed inactivity, not only smoking from the and health alcohol sector consumption.perspective butThese also issues from area broader addressed social not and only from the health sector perspective but also from
12 State of Health in the EU · Italy · Country Health Profile 2019 hesitancy andanti-vaccine movements inItaly. constitutes oneof thefactors that bolsters vaccine restored. Weak policycoherence by thegovernment enforcement of thevaccination obligation was measles cases inthefollowing month,after which a medicalcertificate. Thisresulted inasurge in based onself-declaration rather thansubmitting certify theirchildren’s vaccination status to schools, 2018 whenthenew government allowed parents to Implementation of theplanwas weakened inJune vaccination for theirchildren of any age. also aproposal to impose fines for parents refusing to attend kindergarten andnursery, andthere was became arequirement for children aged upto 6years In addition, inSeptember 2017, proof of vaccination free andmandatory for children attending school. July 2017 theItaliangovernment made ten vaccines As aresponse to the2016-17 measles outbreaks, in vaccinations. that question theefficacy, safety andneedfor to theaction of various groups inItaliansociety vaccine hesitancy continues to beanissue owing between regions. Despite thisstep forward, but also outlines actions to reduce disparities schedules. Theplansets targets for vaccine coverage, previously acombination of 20 different regional 2017, harmonisingasinglenational schedule that was A national vaccination planwas approved inJanuary is hindered by misinformation Box 3. Implementation of anational vaccination plan plan sofar(Box 3). coherence have hindered theimplementation ofthis school attendance, butmisinformationand weak policy coverage, including by making itarequirement for comprehensive two-year plan toincrease vaccination response, in2017theItalian government adopteda and parental trustinthebenefitsof vaccination. In communicable diseases, becauseofreduced public the population against thespread ofarange of the 95%target recommended by WHO to protect 2016,Until childhood vaccination rates below fell children isakey challenge Raising immunisation rates among different regional schedules. Theplansets targets schedule that was previously acombination of 20 January 2017, harmonisingasinglenational A national vaccination planwas approved in vaccination planishindered by misinformation Box 3. Implementation of anational movements inItaly. that bolsters vaccine hesitancy andanti-vaccine by thegovernment constitutes oneof thefactors obligation was restored. Weak policycoherence after whichenforcement of thevaccination a surge inmeasles cases inthefollowing month, submitting amedicalcertificate. Thisresulted in schools, based onself-declaration rather than to certify theirchildren’s vaccination status to 2018 whenthenew government allowed parents Implementation of theplanwas weakened inJune their children of any age. impose fines for parents refusing vaccination for and nursery, andthere was also aproposal to children aged upto 6years to attend kindergarten proof of vaccination becamearequirement for attending school. Inaddition, inSeptember 2017, ten vaccines free andmandatory for children in July2017 theItaliangovernment made As aresponse to the2016-17 measles outbreaks, and needfor vaccinations. Italian society that question theefficacy, safety an issue owing to theaction of various groups in step forward, vaccine hesitancy continues to be reduce disparities between regions. Despite this for vaccine coverage, butalso outlines actions to State of Healthin the EU ·Italy ·Country Health Profile 2019 Italy donot meet theWHOtarget Figure 10. Childimmunisation rates for measles in vaccination. misperception aboutthebenefitsandrisksofthis partly duetothe spread ofmisinformationand vaccinated has declined over thelastdecade, again WHO target of75 %. The proportion ofolder people against influenza in2017, belowwell the recommended than halfof people aged 65andover were vaccinated Although above theEUaverage, only slightly more vaccinated. majority ofcases were among people who hadnotbeen notification rate of measles inEurope. The vast were registered inItaly, giving itthefourthhighest Between 2017and2019, several measlesoutbreaks below thatlevel formeasles(Figure 10). B forthefirsttimesince2014, butit remained slightly target fordiphtheria, tetanus, pertussis andhepatitis increased slightly andagain reached the95% WHO In 2017and2018, vaccination coverage among children 2017). 2019 andEurostat Database for people aged 65 andover (data refer to Source: WHOdata for children (data refer to 2018); OECD Health Statistics and hepatitis B, andthefirst dose for measles. Note: Thedata refer to thethird dose for diphtheria, tetanus andpertussis, Amon chldrened2 Amon peopleed65ndover Influenz Amon chldrened2 Hept t s B Amon chldrened2 Mesles D phther , tetnus,pertuss s 95 95 93 52 % % % % Itl
EU 44 % 93 % 94 % 94 % 13
ITALY Effective primary care is helping lowest in the EU (Figure 11). This reflects a strong keep people out of hospital primary care system, where GPs act as gatekeepers ITALY and growing numbers of multidisciplinary teams The rate of hospital admissions for chronic diseases provide acute and chronic care, as well as preventive such as asthma, chronic obstructive pulmonary services for the whole population. disease (COPD) and diabetes in Italy is among the
Figure 11. Avoidable hospital admissions for chronic diseases are well below the EU average
Asthm nd COPD Conestve hert flure Dbetes Ae-stndrdsed rte of vodble dmssons per 100 000 populton ed 15+ 1 000
800
600
400
200
0
Itl Spn EU21 Irelnd Frnce Mlt Polnd Icelnd Eston Sweden Norw Fnlnd Belum Austr Czech Portul Sloven Denmr GermnSlov HunrLthun Netherlnds Unted ndom
Source: OECD Health Statistics 2019 (data refer to 2017 or nearest year).
Hospitals generally provide high-quality Figure 12. Mortality rates following hospital treatment for people requiring acute care admission for AMI are among the lowest in the EU
The quality of acute care in hospitals for Acute Mocrdl Infrcton Stro e life-threatening conditions such as acute myocardial 2007 (or nerest er) 2017 (or nerest er) 2007 (or nerest er) 2017 (or nerest er)
infarction (AMI) has improved over the past decade 30-d mortl t rte per 100 hosp tl st ons 30-d mortl t rte per 100 hosp tl st ons
and compares well with other EU countries, as 20 30 measured by mortality rates following hospitalisation 25 15 (Figure 12). In 2012, the National Outcomes 20 Programme (Programma Nazionale Esiti, PNE) was 10 15 initiated to assess and support improvements in 10 clinical processes and outcomes. Managed by the 5 5 Italian National Agency for Regional Healthcare 0 0 Services (AGENAS), the Programme provides a
national comparative assessment of effectiveness, EU13 Itl Sp n EU11 Sp n Itl Ltv Polnd Ltv Eston Czech F nlnd SwedenIcelnd Norw Czech Icelnd Sweden F nlndNorw safety and quality of care within the NHS. The results L thun Denmr Sloven L thun Sloven Denmr Luxembour Luxembour at national and regional levels are periodically Un ted ndom Un ted ndom published on a website and used in audits and to provide feedback to improve clinical practices. Note: Figures are based on patient data and have been age-sex standardised to the 2010 OECD population aged 45+ admitted to hospital for AMI. Source: OECD Health Statistics 2019 (data refer to 2017 or nearest year).
14 State of Health in the EU · Italy · Country Health Profile 2019 0 5 10 15 20 Source: Eurostat Database, based onEU-SILC (data refer to 2017). the data across countries asthere are somevariations inthesurvey instrument used. Note: Data refer to unmet needs for amedical examination ortreatment dueto costs, distance to travel orwaitingtimes. Caution isrequired incomparing Figure 14. Unmet medicalcare needsare low, butdisparities are widerthantheEU average and waiting timesissues. The proportion ofunmet medical care in2017(Figure 14), driven mainly by cost about 2%ofthe population reported unmetneeds for cost inhospitalsandconsultations with doctors. Only covered by theNHS, which covers mostofthemedical As notedinSection4, nearly Italianresidents all are are close to the EUaverage Unmet needsformedicalcare 5.2. cancer are slightly higherinItaly thaninotherEU survival rates following diagnosis fortheseandother Despite theserelatively low screening rates, five-year of 66%. over the past three years, compared totheEUaverage with only around 40%of women aged 20-69screened Screening rates forcervicalcancerare much lower, years in2017, which isclose totheEUaverage of61%. been screened forbreast cancerover the past two 60 %of women inthetarget age group of50-69had populations, coverage remains limited. Only about are offered free ofcharge fortheirrespective target and colorectal cancer. Although these programmes common typesofcancersuch asbreast, cervical over thelastdecadeto promote screening for Severalscreeningnational plans werein place put despite relatively low screening rates Cancer survival rates areabove the EUaverage % report n unmet med clneeds Eston
Greece Accessibility
Ltv Romn
F nlnd
Sloven
Un ted n dom Polnd
Icelnd
Irelnd
Slov
Portu l
Bel um
Bul r State of Healthin the EU ·Italy ·Country Health Profile 2019
Itl
EU in the highest quintile (lessthan1%).in thehighestquintile lowest (almost5%)thanamong incomequintile those medical care needs was greater among people inthe Medicine. Source: CONCORD programme, London Schoolof HygieneandTropical Note: Data refer to people diagnosed between 2010 and2014. are above theEU average Figure 13. Five-year survival rates for various cancers timely treatments forcancer patients. system is generally ableto provide effective and countries (Figure 13), suggesting thatthehealth Crot 2019a). higher insouthernregions (European Commission, due to waiting timesandtravel distancesare also wealthier regions inthenorth. Reported unmetneeds report unmetmedicalcare needsthanthose living in poorer regions inthesouthalmost twiceaslikely to in accesstocare across regions, with citizensfrom Unmet needsdataalsosuggestsizeabledisparities
Itl EU26 87% Prostte cncer Cprus
L thun
90 Itl EU26 60% Colon cncer % Sweden 64 H h ncome Norw %
Denmr
Hun r
Frnce Totl popult on Czech
Luxembour EU26 15% Itl Lun cncer 16 Itl Austr EU26 83% Brest cncer %
Germn 86 % Mlt Low ncome
NetherlndsSp n 15
ITALY A new government plan to reduce waiting services, but comparable data are readily available times has recently been adopted only for elective surgery. Compared with other EU ITALY countries with available data, Italy fares well in terms As in many other NHS systems, waiting times have of waiting times for elective surgery such as cataract been a longstanding issue in the Italian health removal and hip replacement (Figure 15), although system and subject to numerous debates and policy there are variations across regions. initiatives. They can exist for a range of health
Figure 15. Waiting times for elective surgery are lower in Italy than in many European countries
C t r ct surer Hp repl cement Med n w t n t mes (ds) 2018 or ltest 2013 Med n w t n t mes (ds) 2018 or ltest 2013 150 150
125 125
100 100
75 75
50 50
25 25
0 0
Itl Sp n Itl Sp n Sweden F nlnd Norw Sweden F nlnd Norw Denmr Hunr Portul Denmr Hunr Portul
Un ted ndom Un ted ndom
Note: The data relate to median waiting times. Source: OECD Health Statistics 2019.
In early 2019, the Ministry of Health adopted a new Out-of-pocket payments are high, driven by three-year national plan on waiting lists, which outpatient medical care and pharmaceuticals requires regions to set maximum waiting times for all health services. Regional unique booking Following the economic crisis, the share of OOP centres will be created to improve the management payments in health spending increased from of appointments and to make the information 21 % in 2009 to 23.5 % in 2017, as cost-sharing accessible in real time through online platforms. If the requirements increased for many health services and maximum waiting times cannot be met, patients will pharmaceuticals in several regions. This is well above be able to access the services with another provider in the EU average of 16 % (Figure 16). proximity, without additional costs.
In June 2019, the National Observatory on Waiting Lists was set up in the Ministry of Health to support the regions in implementing the plan and to monitor waiting times across the country.
Figure 16. OOP payments make up a higher proportion of health spending than the EU average
Overll shre of Dstrbuton of OOP spendn Overll shre of Dstrbuton of OOP spendn helth spendn b tpe of ctvtes helth spendn b tpe of ctvtes
It l EU Inp tent 13% Inp tent 14% Outp tent Outp tent medc l c re 31% medc l c re 91% OOP OOP Ph rm ceutc ls 55% 235% 158% Ph rm ceutc ls 66% Dent l c re 25% Lon-term c re 25% Lon-term c re 24% Others 40% Others 09%
Note: OOP payments for dental care in Italy are included in outpatient medical care. Source: OECD Health Statistics 2019 (data refer to 2017).
16 State of Health in the EU · Italy · Country Health Profile 2019
Others
Lon-term c re Not OOP OOP Dent l c re
Not OOP OOP ph rm ceutc ls
Outp tent medc l c re
Inp tent that period. by aninflow of1100 foreign-trained doctorsduring elsewhere inEurope. This was only marginally offset emigrated tofindinternshipsor regular positions 8 800new medical graduates orfully trained doctors surgeons). As aresult, between 2010and2018, over 2 000andEUR500 per month, even for general salaries ofdoctorsinItaly are very low (between EUR advantage ofbetterjobopportunities, asentry-level trained doctorsinItaly alsomoved abroad totake specialty training. Inaddition, anumber ofnewly so many decided to go abroad tocomplete their at alevel significantly below the number of graduates, their training becausethenumber of places iscapped internship andspecialtytraining place tocomplete of thesenew graduates were notabletofindan from about6700toover 8000. However, many graduates from Italianmedicalschools increased Between 2010and2016, thenumber ofmedical starting theircareers. outflows ofnew medical graduates and young doctors retire. These bottlenecks alsoresult inlarge migration replace thelarge number ofdoctors who are soonto training andrecruitment ofnew doctorsneededto personnel are heightenedby bottlenecks inthe Concerns aboutthefuture availability ofmedical Source: OECD Health Statistics andEurostat Database (data refer to 2017). Figure 17. Themajorityof Italiandoctors are expected to retire inthecoming decade product andthat ofacheaper alternative). the difference between the price ofthe purchased regional co-payments andco-payments resulting from (for non-reimbursed medicines and when there are patients),diagnostic proceduresand pharmaceuticals referral (withoutareferral, costis thefull paid by co-payments are levied onspecialist visits with aGP of OOPspending. GPconsultationsareWhile free, Outpatient pharmaceuticals constituteabout30% of thetotal(of which abouthalfisondentalcare). on outpatientmedicalcare, making upabout40% A large proportion ofOOP payments inItaly are spent 60 40 % of doctors ed 55 ndover 20 50 30 10 0
Itl Bulr
Ltv
Eston
Frnce Germn
Bel um
Cprus Luxembour
Hunr
Icelnd
L thun
Czech
State of Healthin the EU ·Italy ·Country Health Profile 2019 Slov
EU26 in theEU(Figure 17). doctors were aged 55 years andover, thehighestshare future. In2017, more thanhalfofItaly’s practising respond tothehealth needsofthe population inthe ofthehealthsystemto concerns abouttheability age composition ofcurrently practising doctorsraises higherthantheEUaveragestill (seeSection4), the Although thenumber ofdoctors per capita inItaly is new doctorsraise concernsabout shortages Bottlenecks in training andrecruitment of implementation. may berequired toremove barrierstofurther to beemerging inItaly, butregulatory changes findings suggestthat, in practice, taskshifting seems in AMI management (Maieretal., 2018). These there hadbeenanexpansionoftherole ofnurses management. Furthermore, over 50%reported that the past five years inthefield of breast cancer that changes tonurses’ roles hadoccurred over patients, around 30%ofrespondents reported health professionals, healthcare managers and However, inasurvey conductedin2015-16among shifting, asisthecaseinseveral otherEUcountries. been revised inItaly toallow new roles andtask The regulatory framework fornursing hasnot yet roles remainslargely untapped The potential forexpansionofnursing retiring. permanent contracts toreplace doctors who are 2019, providing more to flexibility tooffer regions of employment contracts, adecree was adoptedin growing shortages. To improve theattractiveness jobhospital truststofill vacancies, resulting in the capacities ofsomelocalhealthunitsand The limitedsupply ofnew doctorsisstraining Sp n
Sweden
Denmr
Austr
Sloven
Crot
Greece
F nlnd Netherlnds
Norw
Romn
Irelnd Un ted ndom Mlt 17
ITALY 5.3. Resilience2 ITALY Health spending fell after the economic crisis 0.2 % per year on average in real terms between in 2008, but has been stable in recent years 2010 and 2017 (Figure 18). As GDP grew slightly more rapidly during that period, public health spending as a Following the economic crisis in 2009 and slow share of GDP decreased slightly from 7.0 % in 2010 to economic growth in recent years, public health 6.5 % in 2017. spending in Italy grew at a very modest rate of about
Figure 18. Public spending on health has been stable in recent years Annul chne n rel terms GDP Publc spendn on helth 4%
3%
2%
1%
0%
-1%
-2%
-3%
-4%
-5%
-6% 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017
Source: OECD Health Statistics 2019; Eurostat Database.
Looking ahead, as for many other EU Member States, Hospital capacity has been reduced while population ageing and moderate economic growth are more appropriate care is promoted expected to put pressure on public spending on health and long-term care in the coming years and decades. In line with the trend observed in almost all EU Recent estimates project that public spending on countries, between 2000 and 2017 the number of health will increase by 0.7 percentage point of GDP hospital beds per capita in Italy decreased by about between 2016 and 2070, while public spending on 30 % to 3.2 beds per 1 000 population, well below long-term care is projected to grow by 1.3 percentage the EU average (Figure 19). The number of hospital points, both broadly in line with the EU average discharges decreased in parallel with the number (European Commission-EPC, 2018). of beds, while the average length of stay (ALOS) increased slightly, due at least partly to sicker patients being treated in hospital and an increased use of outpatient care for less severe cases.
Figure 19. Hospital bed numbers have decreased, while the average length of stay has increased
Itl Beds ALOS EU Beds ALOS Beds per 1 000 populton ALOS (ds) 8 10
7
6 8 5
4
3 6 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017
Source: Eurostat Database.
2: Resilience refers to health systems’ capacity to adapt effectively to changing environments, sudden shocks or crises.
18 State of Health in the EU · Italy · Country Health Profile 2019 -05% Avere nnulrowth rte of C-sectons, pst 10ers Source: OECD Health Statistics 2018; Eurostat Database (data refer to 2000 and2016, orthenearest years). Figure 21.Day surgery hasincreased rapidly for some interventions inItaly most patients toreturn homeassoon possible. hospital resources andrespond tothe preference of in recent decadestoreduce theunnecessaryuseof The development ofday surgery hasbeena priority but furtherprogress ispossible Day surgeryhasincreasedsubstantially, Source: Eurostat Database, except Netherlands Perinatal registry (www.perined.nl/) (data refer to 2016 andthegrowth rate between 2006 and2016). Figure 20. Despite reductions, important C-section rate remains highandabove theEU average highest in western European countries. There are to 35%in2016, butnonethelessremains oneofthe decreased over the past decadefrom 39%in2006 example, thecaesarean section(C-section)rate low-value care andunnecessaryinterventions. For Some progress hasbeenachieved inreducing efficiency and appropriateness ofcare inhospital. improveto government purchasing,operational Since 2010majorinitiatives have beenlaunched % of d sur eres 100 -10% -15% 20% 05% 30% 25% 10% 80 60 90 40 15% 20 50 30 70 10 0% 0 15 NL FI Itl Ctrct SE EU 20 20 D FR BE Itl State of Healthin the EU ·Italy ·Country Health Profile 2019 In unl hern ES 25 25 budget. is rewarded by a3%increase intheregional health performance across these indicatorsand progress and monitored by theMinistryofHealth. Good 35 indicatorsfor which regional targets are set Since 2012, C-sectionrates have beenoneof others (Figure 20). with rates insome regions more thandoublethosein somelargestill regional variations inC-sectionrates, countries andtheUnitedKingdom (OECD/EU, 2018). levels reached inleading countriessuch astheNordic However, further progress is still toattain possible least equaltotheEUaverage ifnot greater (Figure 21). increased markedly inItaly since2000andare now at and tonsillectomy performed asday caseshave The shares ofcataract surgery, inguinal herniarepair EU14 EU U Ranging from 22% to 54%acrossRanging regions from 22% Number of C-sectons per100lve n2016 brths AT Itl 30 30 DE Tonsllectom LU IE PT 2000 EU 2016 IT 35 19
ITALY Measures have been implemented to the NHS – a mechanism known as ‘pay-back’. If the contain pharmaceutical spending hospital inpatient expenditure cap is exceeded, the ITALY regions and manufacturers are liable to refund 50 % Pharmaceutical expenditure in Italy is a major each of the excess expenditure to the NHS. component of public spending on health. Regulatory measures, such as spending ceilings, have been In order to monitor the dynamics of pharmaceutical introduced to contain pharmaceutical expenditure expenditure and GP prescriptions, a comprehensive outside hospital and in hospital, with mixed success. information system called Sistema Tessera sanitaria has been implemented, which keeps track of Ceilings for reimbursable pharmaceutical spending ePrescriptions and other health data at the patient in retail pharmacies were first introduced in 2001. level (European Commission, 2019b). These were initially capped at 13 % of total health expenditure per year at both national and regional Financial disincentives for pharmacists have levels, then reduced to 11 % in 2013 and to 8 % in stifled the increase in the uptake of generics 2017. In 2003, spending ceilings were also introduced for medicines delivered by hospital pharmacies for To improve value for money in pharmaceutical inpatients and outpatients. The ceilings for hospital spending, Italy has implemented a series of measures pharmaceutical expenditure were initially set at to promote greater use of generics. Unless a reason is 2.4 % of total health expenditure, but then increased provided by the doctor to preclude substitution, the to 3.5 % in 2013 and 6.9 % in 2017. These increases pharmacist must mention to customers if a cheaper reflect the fact that new medicines used in hospitals equivalent product exists. If the doctor indicates that are becoming more costly. For example, expenditure the medicine is ‘not substitutable’ or if the customer on cancer drugs increased by 12 % from 2016 to insists on purchasing the brand name, the customer 2017, accounting for almost 23 % of total public must pay the difference between the price of the pharmaceutical expenditure in the country in 2017 dispensed medicine and the cheapest alternative. (AIFA, 2018). Between 2005 and 2017, the generics market share in To avoid overspending, some agreements between Italy increased from 7 % to 25 % in volume (Figure 22). industry, regions and the NHS have been established. Nevertheless, the share remains well below the EU If the ceiling on community pharmacy expenditure average, in part because pharmacists are remunerated is exceeded, the industry (manufacturers and according to a fixed percentage of the price of each distributors) is liable to refund the excess spending to product, which creates a disincentive for them to dispense (cheaper) generic medicines.
Figure 22. The use of generic medicines in Italy is well below the EU average
Itl Spn Unted n dom EU17
90% 80% 70% 60% 50% 40% 30% 20%
10%
0% 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017
Note: Data refer to the share of generics by volume for the whole market, including community pharmacies and hospitals. Source: OECD Health Statistics 2019.
Reducing variation in use of biosimilars reference medicines have the same therapeutic could help contain pharmaceutical costs benefits, it did not require automatic substitution between the two products. Once a biosimilar is In December 2016, a new law was approved to available on the regional market, a physician can improve access to biosimilars. The Italian Medicines decide whether to switch to the new treatment option Agency adopted specific rules, including on or not. In Italy, as in many EU countries, the uptake of the substitutability of products and the public biosimilars varies greatly by product and therapeutic procurement of biosimilars through regional tenders. area (Figure 23). While the Agency recognised that biosimilars and
20 State of Health in the EU · Italy · Country Health Profile 2019 (Ministry ofHealth, 2017). ePrescriptions andtelemedicineacross regions further will promote theimplementation ofEMRs, system. This Triennial Planincludes initiatives that created to guide ofthe thedigitalisation public health Public Administration Informatics2019-2021 was Strategy Growth forDigital and Triennial Planfor management andexperience. Following this, the innovations thatcould improve patient workflow records (EMRs), telemedicinesystemsandICT priorities were thedevelopment ofelectronic medical in acoordinated way across thecountry. The main to manage and promote thediffusionofeHealth In 2016, Health theDigital Agreement was reached going at adifferent paceacross regions The digitalisation of the healthsystemis campaigns have beendeveloped. and only relatively awareness-raising small-scale programmes islimitedtosomehealthcare facilities, implementation ofantimicrobial stewardship plan andmonitoring arrangements. However, the antimicrobial resistance, including anoperational Italy hasamulti-sectoral plan totackle (OECD, 2018). estimated ataround EUR600000 per 100000 people and isthehighestinEU, with anannual cost the Italianhealthsystem’s budgetisalsosubstantial, continue. The impact ofantimicrobial resistance on consumption,economic growthand population further inthefuture ifcurrent trends inantibiotic from 17%in2005to302015, andcould increase resistant infections hasincreased inrecent years, per 100000 population in2015. The proportion of in theEU, with anestimatedmortalityrate of18.2 infections resistant to antimicrobial treatments Italy hasthehighest number ofdeathsdueto health andeconomicissueinItaly Antimicrobial isamajor resistance and 2016). Source: IMSInstitute for Healthcare Informatics (2016) (data refer to 2015 therapeutic areas Figure 23. Theuptake of biosimilars isuneven across failure are biosimilars inItaly medicines for patients withrenal Only are biosimilars inItaly medicines for rheumatoid arthritis % 57 0% 20 of market share for some of market share for some (EU: 24%) (EU: 45%) State of Healthin the EU ·Italy ·Country Health Profile 2019 medical records varies widelyacross Italy Figure 24. Theshare of doctors usingelectronic were using them(Figure 24). in 2019, ineightregions more than80%ofdoctors nodoctorhadeverWhile usedEMRsinseven regions uptake Regional ofEMRsstill varies considerably. since toimplement telemedicineoptions. development oftelemedicine, butlittlehasbeendone defined general standards to promote the In 2014, theNationalGuidelines for Telemedicine than 90%ePrescription rates. 2017, 17ofthe20regional healthsystemshadmore supported theimplementation ofePrescriptions. In procedures. A seriesofregulations thenfurther 2009, andin2011setoutmore specifictechnical ePrescriptions formedicinesandtreatments in The legalframework firstdefinedtheconcept of fascicolosanitario.gov.it/ Fascicolo Sanitario Elettronico (data refer to 2019), https://www. Source: Agencyfor theDigitalisation of thePublicAdministration. usn EMR Percente ofdoctors 80 -100% 20 -80% 0 -20% 21
ITALY ITALY 6 Key findings
• The health of the Italian population is • Italy has faced important challenges in generally good and life expectancy is the restoring public trust in the benefits of second highest in the EU after Spain, but gaps vaccination: inadequate vaccination coverage, persist by socioeconomic status and region. both now and in the past, has led to several The least educated men live 4.5 years less measles outbreaks in recent years. A national than the most educated (which is nonetheless vaccination plan was approved in 2017, a smaller gap than the EU average), and the creating a single national vaccine schedule, gap in life expectancy between those living in and including ten mandatory vaccines for southern and northern regions can reach up children. However, misinformation and weak to three years in favour of the latter. policy coherence continue to hinder the implementation of this plan. • Although tobacco-control policies have succeeded in reducing smoking rates among • While the numbers of doctors and nurses per adults, the proportion of adolescents and population have slightly increased over the adults who smoke remains higher than the past decade, there are growing concerns about EU average. While obesity among adults is workforce shortages, with more than half of lower than the EU average, the proportion of all doctors over the age of 55. The training children and adolescents either overweight and recruitment of new doctors has been or obese is greater. In February 2019, the limited in recent years due to a shortage of Ministers of Health and Education adopted a internship and postgraduate specialty training set of integrated policy guidelines to promote places and good job opportunities for newly better nutrition, physical activity and other trained doctors, which led to the emigration of health promotion activities in schools. many medical graduates and young doctors. The scope of practice of nurses remains • Following the economic crisis in 2008-09, limited and no expansion has been envisaged health spending fell initially, but has to improve both access to care and career remained stable in recent years. Health prospects for nurses. spending accounted for 8.8 % of Italy’s GDP in 2017, a lower share than the EU average • As in other EU Member States, population of 9.8 %. About three-quarters of health ageing and moderate economic growth are spending is publicly funded, a lower share projected to put pressure on public spending than in 2010 (79 %) and lower than the current on health and long-term care in the coming EU average (79 %). Out-of-pocket payments years and decades. Better coordination across increased following the introduction of new the country in the development of digital co-payments for many health services and health solutions could help improve access pharmaceuticals after the economic crisis. and efficiency in health service delivery. Unmet needs for medical care are generally
low, although they are higher for people on low incomes.
• Italy can build on a strong primary care system to address the needs of an ageing population. Several regions are piloting new service delivery models, adding multispecialty community-based centres and intermediate care facilities between primary care and hospitals, developing case management capacity and combining them with social care. Although these initiatives aim to identify new models of chronic care, most of these pilots have not been subject to a formal evaluation process yet.
22 State of Health in the EU · Italy · Country Health Profile 2019 Key sources
Ferré F, et al. (2014), Italy: Health System Review, Health OECD/EU (2018), Health at a Glance: Europe 2018: State Systems in Transition, 16(4):1–168. of Health in the EU Cycle, OECD Publishing, Paris, https:// doi.org/10.1787/health_glance_eur-2018-en.
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Country abbreviations
Austria AT Denmark DK Hungary HU Luxembourg LU Romania RO Belgium BE Estonia EE Iceland IS Malta MT Slovakia SK Bulgaria BG Finland FI Ireland IE Netherlands NL Slovenia SI Croatia HR France FR Italy IT Norway NO Spain ES Cyprus CY Germany DE Latvia LV Poland PL Sweden SE Czechia CZ Greece EL Lithuania LT Portugal PT United Kingdom UK
State of Health in the EU · Italy · Country Health Profile 2019 23 State of Health in the EU Country Health Profile 2019
The Country Health Profiles are an important step in Each country profile provides a short synthesis of: the European Commission’s ongoing State of Health in the EU cycle of knowledge brokering, produced with the ·· health status in the country financial assistance of the European Union. The profiles ·· the determinants of health, focussing on behavioural are the result of joint work between the Organisation risk factors for Economic Co-operation and Development (OECD) and the European Observatory on Health Systems and ·· the organisation of the health system Policies, in cooperation with the European Commission. ·· the effectiveness, accessibility and resilience of the The concise, policy-relevant profiles are based on health system a transparent, consistent methodology, using both quantitative and qualitative data, yet flexibly adapted The Commission is complementing the key findings of to the context of each EU/EEA country. The aim is these country profiles with a Companion Report. to create a means for mutual learning and voluntary For more information see: ec.europa.eu/health/state exchange that can be used by policymakers and policy influencers alike.
Please cite this publication as: OECD/European Observatory on Health Systems and Policies (2019), Italy: Country Health Profile 2019, State of Health in the EU, OECD Publishing, Paris/European Observatory on Health Systems and Policies, Brussels.
ISBN 9789264725935 (PDF) Series: State of Health in the EU SSN 25227041 (online)