Universal Health Coverage in Italy: lights and shades of the Italian National Health Service which celebrated its 40th anniversary

Journal Pre-proof Universal Health Coverage in Italy: lights and shades of the Italian National Health Service which celebrated its 40th anniversary C. Signorelli, A. Odone, A. Oradini-Alacreu, G. Pelissero

PII:

S0168-8510(19)30259-3

DOI:

https://doi.org/10.1016/j.healthpol.2019.11.002

Reference:

HEAP 4171

To appear in:

Health policy

Received Date:

9 May 2019

Revised Date:

9 October 2019

Accepted Date:

5 November 2019

Please cite this article as: Signorelli C, Odone A, Oradini-Alacreu A, Pelissero G, Universal Health Coverage in Italy: lights and shades of the Italian National Health Service which celebrated its 40th anniversary, Health policy (2019), doi: https://doi.org/10.1016/j.healthpol.2019.11.002

This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Published by Elsevier.

Universal Health Coverage in Italy: lights and shades of the Italian National Health Service which celebrated its 40th anniversary Signorelli C 1,2, Odone A1, Oradini-Alacreu A1, Pelissero G3. Affiliations: 1. 2. 3.

School of Medicine, University Vita-Salute San Raffaele, Milan, Italy Department of Medicine and Surgery, University of Parma, Italy. Department of Public Health, Experimental and Forensic Medicine, University of Pavia, Pavia, Italy.

ro of

Corresponding author: Prof. Carlo Signorelli School of Medicine University Vita-Salute San Raffaele

-p

Via Olgettina, 58 20132 – Milano (Italy)

re

mail: [email protected]

Highlights

lP

40-year-old Italian National Health Service is unique example of universal health coverage. I-NHS has reached excellent standards of efficiency despite financial constraints. I-NHS has incorporated public-private partnership in healthcare maintaining universality, equity, solidarity.

na

  

ur

Abstract

Jo

The Italian National Health Service (I-NHS) was established in 1978 to guarantee universal access to healthcare. As emerges from international reports, in forty years, the I-NHS has reached a satisfactory level of efficiency and excellent standards of care in many regions. Along the years, I-NHS has developed a structural public-private partnership in health services delivery that in some regions contributes to the achievement of very high standards of healthcare quality. However, the I-NHS is currently facing some major challenges: (a) Italy is experiencing a remarkable aging of its population with increasing health needs; (b) the recent and constant cuts to public expenditures are reducing the budget for welfare. It is of utmost importance to ensure that on-going efforts to contain health system costs do not subsume health care quality. In addition, monitoring of the essential levels of care (Livelli Essenziali di Assistenza, LEA) highlights significant differences in healthcare delivery among Italian regions that, in turns, contribute to the burdensome migration of patients to best-performing regions. Therefore, a more consolidated and ambitious approach to quality monitoring and healthcare improvement at a system level is needed to guarantee its sustainability in the future

Keywords: National Health Service; Universal Health Coverage; Italy; Private providers.

1. Introduction In 2018 we celebrated key anniversaries for the right to health and healthcare: 40 years since the Declaration of Alma-Ata identified primary health care as the key to the attain Health for All, and 70 years since the British National Health Service (NHS) was established, one of the first national health services to provide Universal Health Coverage (UHC) in Europe (1, 2). In 2018 we also celebrated the 40th anniversary of the Italian National Health Service (I-NHS), one of the few health system still providing UHC. The I-NHS was established, after a long gestation, on December 23rd 1978 with law n. L.833/78, replacing a system based on insurances (i.e. a Bismarck model (3).

ro of

The I-NHS was founded with the guiding principles of universality and solidarity. These derive from Article 32 of the Italian Constitution, which recognizes health as a fundamental right both for the individuals and as a collective interest. Indeed, I-NHS ensures access to healthcare to all citizens, without discrimination by income, gender or other determinants, complying with the World Health Organization (WHO) principle of the UHC.

re

-p

According to the Constitution, the I-NHS follows a Beveridge model (3) with some peculiarities broadened over time. Instead of a highly centralized system with the national government as the sole payer, the I-NHS structure, through the Legislative Decrees 502/1992 and 517/1993 and 299/1999, leave substantial power to the 19 regions and 2 Autonomous Provinces of the country which are responsible for the planning and delivery of healthcare services (4) through a multi-layered organization involving the central government, the regional governments and approximately 100 Local Health Authorities (LHA or ASL) (5).

na

lP

Another peculiarity of the I-NHS is the pluralism of healthcare providers that are both public and private. The latter must receive institutional accreditation by it’s the regional health governance to deliver health services which are ultimately reimbursed within the I-NHS. The institutional accreditation certifies that providers meet the structural, technological and organizational targets required under current regulations. Indeed, the 1992 reform also conceived a quasi-market based on patients’ choice, a managerial organization of LHA and general hospitals and the challenging competition between public and private providers to improve quality, safety and efficacy of healthcare services.

Jo

ur

Despite some concerns, that will be reported in the current analysis, the I-NHS provides at present times, relatively high standards of healthcare, as demonstrated by the fact that in 2018 Italy ranked fourth in the World rank after Hong Kong, Singapore and Spain in the Bloomberg Health Care Efficiency ranking, scaling up two positions, as compared to 2017 (6). Moreover, Italy ranked second behind France on WHO’s measure of overall health system performance among 191 countries across the globe (7). Furthermore, life expectancy of Italian citizens is among the highest in the world, second in Europe after Spain, although disparities exist across regions and socioeconomic groups. According to the most recent data, in 2017 life expectancy in Italy was 82.8 for the general population (+0.4 years from 2015), 80.5 years for males and 84.9 years for females, (8, 9). At the same time, healthcare expenditure (in relation to GDP) is 8.6% in 2018, with a high proportion of public expenditure (77.3%) (10).

2. Achievements of the I-NHS 2.1. Health outcomes

In Italy AGENAS is the national agency of the Ministry of Health that coordinates the 21 regional healthcare services. One of the main aim of AGENAS is to improve effectiveness and quality of the I-NHS through the evaluation of outcomes from healthcare services. In 2008, AGENAS set up the National Observatory on Good Practices with the objective of encouraging and supporting continuous improvement of quality and safety of care. The Observatory has co-operated to set up the National Outcomes Programme (Programma Nazionale Esiti, PNE) to provide evaluations of effectiveness, fairness, safety and appropriateness of healthcare performances provided by I-NHS, by single healthcare facility and over time Every year since 2013 AGENAS has analysed about 160 outcome indicators such as mortality within 30 days following acute myocardial infarction, proportion of primary Caesarean section, surgery intervention within 2 days from femoral neck fracture and others (11). Aggregated data are published annually and are open-access.

ro of

The Program is based on the analysis of hospital discharge records (SDO), filled by law since 1992 for each individual hospitalization using the Diagnosis-related Group or DRG classification and representing one of the richest and most reliable databases in the world for monitoring hospital activities. The results of PNE clearly show that Italy has good health indicators concerning quality of care, despite discrepancies among regions. For example, the PNE assesses the timely intervention on the femoral neck fracture (12) in Italian hospitals that in the elderly reduces mortality, postoperative complications and improves recovery of functional outcomes.

-p

At the national level, the proportion of femoral neck fractures in patients over 65 years of age managed within 48 hours rose from 31% in 2010 to 60% in 2017. Regional differences still remain with only Northern regions that meeting the Ministerial target of 70% (13).

re

The progressive development of the PNE has allowed the extension of its use also to fix the minimum performances of hospital units to obtain accreditation, to evaluate the performance of the hospitals CEO's and for the accreditation of post-medical residency training (Scuole di Specializzazione) (14).

ur

na

lP

Data from the OECD “State of Health in the EU” are coherent with the PNE figures, suggesting a generally good performance of Italian hospitals with regard to mortality outcomes, although variations arise across the Country. For instance 30-days mortality rates after hospitalization for acute myocardial infarction in Italy are the lowest among EU countries with available data, with only 7.6 deaths per 100 admissions in 2015 (15). Similarly, mortality rates from stroke were among the lowest in Europe in 2015. Avoidable mortality in Italy remains one of the lowest in EU countries, suggesting that the healthcare system is effective in treating people with life-threatening conditions (15).

2.2. Public-private partnership

Jo

Over time, the I-NHS has taken on a “semi-hybrid model” with a relevant contribution of private sector healthcare providers. The private healthcare organizations are necessary to achieve the minimum acceptable performance volumes in many areas of specialist outpatient activity and hospital services. Indeed, in Italy 55.6% of the 1,034 hospitals are private, counting for 30.2% of hospital beds available for the I-NHS (16, 17). Thus 28.3% of hospitalizations among I-NHS are delivered by private accredited hospitals, accounting for 13.6% of the total hospitals’ expenditure in 2017 (18). This difference might be explained by shorter, less complex and less expensive hospitalizations. From 1970s, the number of private providers has increased; the number of hospital beds in accredited private healthcare facilities has risen from 14% in 1980 to 20.9% in 2014 and to 30.2% in 2016. According to the report of the Italian Association of Private hospitals (AIOP) the existence in some Italian regions of private hospitals is an important opportunity for the I-NHS to provide quality healthcare services and a

stimulating a useful competition for the Italian health system (16, 17). This statement is certainly correct and demonstrated for some northern regions where renowned high quality large private hospitals operate, but certainly need more detailed supporting data in the central and southern regions, characterized by the presence of medium and small sized private hospitals.

3. Critical issues 3.1. Regional differences in essential levels of care (LEA) scores The essential levels of care (Livelli Essenziali di Assistenza, LEA) are a set of healthcare performances defined at the central level by the Ministry of Health that the I-NHS ought to provide to all citizens throughout the country.

ro of

LEAs include all healthcare services considered necessary for citizens’ health and wellbeing. The principle of LEAs was introduced in 1999 and became more important after the constitutional reform of 2001 that redistributed powers to the different Italian regions as a way to ensure UHC and homogeneous standards of healthcare for all Italian citizens, no matter the region they come from.

lP

re

-p

Nevertheless nowadays, there are still substantial differences regarding access to LEAs between Italian regions. The 2017 LEA monitoring (Figure 1) showed that 16 regions out of 21 reached and exceed the minimum score fixed by the Ministry of Health (>160) while 5 regions did not. Indeed, eight regions (Piedmont, Veneto, Emilia Romagna, Tuscany, Lombardy, Umbria, Abruzzo and Marche) reached a score over 200, being apparently the best in fulfilling LEA services. Other eight regions scored between 200 and 160 (which is the minimum level acceptable): Liguria, Friuli-Venezia-Giulia, Basilicata, Autonomous of Provinces of Trento and Bolzano, Lazio, Puglia, Molise e Sicily. Campania, Valle d’Aosta, Sardinia and Calabria obtain scores under 160 presenting problems related to the area of prevention (oncological screenings and vaccination coverage) and the area of primary care. With regard to worst performing regions, Calabria has achieved a worse score than last year, while Campania has reached a better score even if still below acceptable standards. Sardinia, Valle d’Aosta and Autonomous Province of Bolzano did not reported to the Ministry part of the data, even if mandatory.

na

In general, LEA monitoring data show that the regions of Southern Italy provide lower standards of healthcare, independently of the funding provided by the State.

ur

This gap underlines the need to develop new solutions to promote the equity of the system, improve effectiveness and tackle territorial health inequalities (19).

Jo

3.2. The I-NHS financial viability

The I-NHS is largely funded through national and regional taxes, supplemented partially by co-payments for pharmaceuticals and outpatient care. In 2018, total Italian healthcare expenditure was 8.6% of the nation’s gross domestic product (GDP); about the European average of 8.8% but far from other European countries such as Germany (11.2%), France (11.2%) and Sweden (11.0%). Even though I-NHS expenditure has increased continuously reaching 115.4 billion euro in 2018, health expenditure, as a percentage of GDP, has dropped in the last years because the Italian GDP experienced a higher decrease (-2.1%, as compared to 2016) (20). The Italian Public Health expenditure, as percentage of GDP, has gradually decreased from 7.3% in 2009 to 6.6% in 2018 (Table 1) (19, 21). In 2019 healthcare expenditure is planned to reach 118.1 billion euro. Indeed, Italy has increased financial resources devoted to public health in recent years, despite the economic crisis and financial constraints on the public sector

(22). The Italian out-of-pocket health expenditure in 2018 was 35.700 billion (2.0% of the GDP), most of it (86.1%) out of pocket. (21). The economic stagnation of Italy (23) and the growth of healthcare costs linked to the ageing of the Italian population and the availability of new (and more expensive) technologies risk to jeopardize I-NHS healthcare provision. The financial sustainability of the I-NHS therefore remains a major concern, and a central regulatory framework of the I-NHS is urgent and necessary.

ro of

In spite of the economic difficulties of the Italian population, the private healthcare spending has raised in the recent years too. According to the report 2018 of the Italian Institute for social study and research (CENSIS) the private healthcare spending reached € 40 billion in 2017 (+ 9.6% compared to 2013). The average outlay per capita has reached 655 euros per year, which is likely to grow to one thousand euros in 2025 with the risk of this becoming an explosive social problem (24). Altogether, more than 10 million Italians are in some way supported by private healthcare funds.

3.3. Regional migration of patients for hospitalization

lP

re

-p

Italian citizens have the right to seek care in any of the 1,067 public or private accredited hospitals (25) of the 21 regional Health Authorities. Every year around 700,000 patients migrate from one region to another to seek healthcare. The number of patients hospitalized outside their place of living has increased in the last 20 years up to 8.2% of total admissions registered in 2014 (18). The migration of patients is usually towards regions where the private sector is more developed and qualified, as private providers tend to be more efficient and prompter in providing health services, especially with regard to the bureaucratic burden. Figure 2 shows in green the regions that claim credits due to patients’ migration, in red the regions that are in debts due to their patients’ outbound migration and in white the regions balancing attraction and migration of patients (from +2 million € to -2 million €) (26).

ur

na

As mentioned before, these figures shows that I-NHS is facing some difficulties in providing uniform LEA throughout the country. It is interesting to observe that in 4 years the Italian regions with attractive capacities have been reduced from 9 to 6, thus highlighting a growing imbalance that affects the planning of hospital beds by the regions, the risks of deficit in the regions with significant migrations for health care and more in general on the lack of equity of the services available for Italian citizens. Nevertheless, the INHS preserves a satisfactory overall level of efficiency of health care.

3.4. Excessive waiting times

Jo

Waiting times arise as the result of the imbalance between the demands for and the supply of healthcare services. Increasing health needs, an ageing population and technological developments are contributing factors to the increased demand for health care services. Furthermore, longer waiting times may induce some patients to seek care in the private sector and push providers to increase production or productivity. In Italy, waiting time is a critical issue especially for outpatient specialist care and diagnostic services, and has been tackled by national plans in the last decade (27). In Italy, recent data, show that 38.7% of adult population (nearly 19.6 million people) have been added to a waiting list in the last 12 months: 30.7% for outpatient medical care and outpatient diagnostics and 8.0% for inpatient care. Furthermore, 15% of patients waiting for inpatient care in public healthcare facilities is on waiting list for longer than 60 days while the percentage is lower than 6.3% in private accredited providers (16).

Excessive waiting times are one of the main obstacles to access to healthcare and policies to reduce waiting time have generally had only a limited impact so far. Recently, in February 2019, in order to tackle this problem, the Ministry of Health has approved a national plan for the governance of waiting lists 2019-2021 (Piano Nazionale Governo liste d’attesa 2019-2021, PNGLA) (28).

4. Future challenges: ageing, appropriateness of healthcare service and financial viability Italy has the oldest population in Europe, with, for 2017, 22.6% of the population aged 65 and over (29). In 2017 the trend of declining fertility rate continued with a drop from 1.46 in 2010 to 1.32 and for, the first time, the number of octogenarians overtaking the number of new-borns. Indeed, the financial and sustainability challenges faced by the healthcare system due to the ageing population, should not be underestimated. If gradual decline of healthcare expenditure in Italy persists, healthcare of the Italian increasingly older population will be a major challenge.

ro of

Another challenge is quality and equity improvement of I-NHS healthcare services in every Italian region. Indeed, the I-NHS will need to improve healthcare services appropriateness under the supervision of the national agency AGENAS to guarantee the maintenance of the quality and equity of services provided.

lP

5. Concluding remarks

re

-p

In summary, the progressively increasing ageing population and the need to invest in new technologies and medical staff to assure the preservation of the three guiding principles of the I-NHS requires appropriate financing. Therefore, financial viability must be urgently redefined taking into account the future challenges that the I-NHS is facing to avoid the collapse of this “priceless” system. This could include a reorganization and rationalization of the hospital network (which is ongoing but too slowly), a review of the co-payment system (tickets) and a debate about the role and function of local services including family doctors.

Jo

ur

na

Despite the highlighted critical issues and the gap between the Northern and Centre-Southern regions, we believe that the I-NHS remains one of the world's health systems that better meets the targets of the UHC, as defined by WHO. It is therefore not incidental that Italian health indicators (such as life expectancy and infant mortality) are among the best performing in the world and Italy ranks very high in many international studies comparing performances of national healthcare systems. Another feature of the I-NHS, not much highlighted in recent papers and reports, is the important role of the private sector as key healthcare provider, delivering about 28% of hospital performances and even higher shares of diagnostic and laboratory services, always monitored by the public health authorities. This peculiarity could be an important model for many countries in order to meet the UHC objective, reserving an important role for private suppliers and in particular for private hospitals. This is one of the reasons that led us to gather in this document some data from the Italian health system as a stimulus to the ongoing debate on the wide extension of the UHC. However, the data presented highlight some critical issues to be corrected by the Italian Government in the coming months to ensure the sustainability of the I-NHS: a substantial increase in public financing, the reduction of regional differences, the strict monitoring of outcomes, the rationalization of private expenditure with the development of complementary health funds and a more clear recognition of the role of the private sector as a fundamental pillar for important performances provided by the I-NHS. (5, 30-51)

Declaration of Interest statement: none to declare

Jo

ur

na

lP

re

-p

ro of

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for profit sectors.

References

Jo

ur

na

lP

re

-p

ro of

1. Watkins DA, Yamey G, Schaferhoff M, Adeyi O, Alleyne G, Alwan A, et al. Alma-Ata at 40 years: reflections from the Lancet Commission on Investing in Health. Lancet. 2018 Oct 20;392(10156):1434-60. 2. The NHS at 70 and Alma-Ata at 40. The Lancet. 2018 Jan 6;391(10115):1. 3. Signorelli C. Igiene e Sanità Pubblica. 2017. SEU. 4. Signorelli C, Fara GM, Odone A, Zangrandi A. The reform of the Italian Constitution and its possible impact on public health and the National Health Service. Health Policy. 2017 Jan;121(1):90-1. 5. Turati G. (2014) The Italian Servizio Sanitario Nazionale: A Renewing Tale of Lost Promises. In: Costa-Font J. and Greer S. (eds.), Federalism and Decentralization in European Health and Social Care, Palgrave MacMillan, London. 6. Bloomberg [Internet]. Bloomberg.com. 2019 [cited 21 January 2019]. Available from: https://www.bloomberg.com/news/articles/2018-09-19/u-s-near-bottom-of-health-index-hong-kong-andsingapore-at-top. 7. Tandon A, Murray CJ, Lauer JA, Evans DB. Measuring overall health system performance for 191 countries. Geneva: World Health Organization. 2000. 8. WHO | Italy [Internet]. Who.int. 2019 [cited 21 January 2019]. Available from: https://www.who.int/gho/countries/ita/en/. 9. OECD Health Statistics 2018 - OECD [Internet]. Oecd.org. 2019 [cited 22 January 2019]. Available from: http://www.oecd.org/health/health-data.htm. 10. OECD Health Statistics 2019 - OECD [Internet]. Oecd.org. 2019. Available from: https://www.oecd.org/health/health-data.htm. 11. Ministero della Salute. Agenzia Nazionale per i Servizi Sanitari Regionali.[Interbet] Programma Nazionale Esiti - PNE 2018. Available from: https://pne.agenas.it/. 12. Edizione 2017 del Programma nazionale esiti - Agenas - Agenzia Nazionale per i servizi sanitari Regionali [Internet]. Agenas.it. 2019 [cited 22 January 2019]. Available from: http://www.agenas.it/primopiano/edizione-2017-programma-nazionale-esiti-2017. 13. World Report on Disability 2011. Geneva: World Health Organization 2011.; 2011. 14. Odone A PG, Signorelli C; Board of Directors of the Italian Postgraduate Schools of Hygiene and Public Health. Post-graduate medical education in public health: the case of Italy and a call for action. Public Health Rev. 2017 Oct 24;38:24. doi: 10.1186/s40985-017-0069-0. eCollection 2017. 15. OECD. European Observatory on Health Systems Policies Italy: Country Health Profile 2017. 16. Delai N. OSPEDALI&SALUTE. Milano: Aiop/Ermeneia2019 2019-01-16. 17. Associazione Italiana Ospedalità Privata (AIOP). II° RAPPORTO SULLA QUALITA’ DEGLI OUTCOMES CLINICI NELL’OSPEDALITA’ PRIVATA (a cura di Innogea Growing healthcare). AIOP: ROma, agosto 2019. 18. Pelissero G. Costruire la Sanità del futuro. Milano: FrancoAngeli 2018. 19. Ministero della Salute [Internet]. Salute.gov.it. 2019 [cited 21 January 2019]. Available from: http://www.salute.gov.it/portale/home.html. 20. CERGAS. Rapporto OASI 2018. Milano: SDA Bocconi2018. 21. 4° Rapporto GIMBE sulla sostenibilità del Servizio Sanitario Nazionale. Fondazione GIMBE: Bologna, giugno 2019. Available from: www.rapportogimbe.it. . 22. Rechel B. Funding for public health in Europe in decline? Health Policy. 2019 Jan;123(1):21-6. 23. Odone A LT, Amerio A, Costa G. The impact of the current economic crisis on mental health in Italy: evidence from two representative national surveys. . Eur J Public Health 2018 Jun 1;28(3):490-495 doi: 101093/eurpub/ckx220. 24. CENSIS. La sanità del rancore, il rancore per la sanità scene da un paese diseguale. RBM assicurazione salute – CENSIS VIII Welfare Day, anno 2018. Roma, 2018. 25. Ministero della Salute. Banca dati del Servizio sanitario nazionale / Database of the I-NHS. Reference year: 2013. Available from: http://www.salute.gov.it/portale/documentazione/p6_2_8_1_1.jsp?lingua=italiano&id=6. 26. Report Osservatorio GIMBE n. 6/2019. La mobilità sanitaria interregionale nel 2017. Fondazione GIMBE: Bologna, luglio 2019. Available from: www.gimbe.org/mobilita2017.

Jo

ur

na

lP

re

-p

ro of

27. Christiansen T, Bech M. Waiting Time Policies in the Health Care Sector. What Works?: DenmarkDanmark. Oecd Health Policy Studies: OECD Publishing; 2013. p. 115-31. 28. Ministero della Salute. Liste di attesa. [Internet] Piano Nazionale Governo Liste di attesa 2019-2021: in sintesi. Available from:http://www.salute.gov.it/portale/listeAttesa/dettaglioContenutiListeAttesa.jsp?lingua=italiano&id=51 40&area=listeAttesa&menu=vuoto. 29. Istat. Bilancio demografico nazionale, anno 2017. Available from: https://www.istat.it/it/archivio/bilancio+demografico2018. 30. Atella V, Belotti F, Bojke C, Castelli A, Grasic K, Kopinska J, et al. How health policy shapes healthcare sector productivity? Evidence from Italy and UK. Health Policy. 2019 Jan;123(1):27-36. 31. de Belvis AG, Ferre F, Specchia ML, Valerio L, Fattore G, Ricciardi W. The financial crisis in Italy: implications for the healthcare sector. Health Policy. 2012 Jun;106(1):10-6. 32. Ferre F, Cuccurullo C, Lega F. The challenge and the future of health care turnaround plans: evidence from the Italian experience. Health Policy. 2012 Jun;106(1):3-9. 33. Ferre F, de Belvis AG, Valerio L, Longhi S, Lazzari A, Fattore G, et al. Italy: health system review. Health Syst Transit. 2014;16(4):1-168. 34. France G, Taroni F, Donatini A. The Italian health-care system. Health Econ. 2005 Sep;14(Suppl 1):S187-202. 35. Gaeta M, Campanella F, Capasso L, Schifino GM, Gentile L, Banfi G, et al. An overview of different health indicators used in the European Health Systems. J Prev Med Hyg. 2017 Jun;58(2):E114-E20. 36. Grima S, Spiteri JV, Jakovljevic M, Camilleri C, Buttigieg SC. High Out-of-Pocket Health Spending in Countries With a Mediterranean Connection. Front Public Health. 2018;6:145. 37. La Torre G, Federici A. How to not detonate the bomb: the case of the Italian National Health Service. Public Health. 2017 Dec;153:178-80. 38. Longo F. Lessons from the Italian NHS retrenchment policy. Health Policy. 2016 Mar;120(3):306-15. 39. Mauro M, Maresso A, Guglielmo A. Health decentralization at a dead-end: towards new recovery plans for Italian hospitals. Health Policy. 2017 Jun;121(6):582-7. 40. Ongaro E, Ferre F, Fattore G. The fiscal crisis in the health sector: Patterns of cutback management across Europe. Health Policy. 2015 Jul;119(7):954-63. 41. Signorelli C, Ricco M, Odone A. The Italian National Health Service expenditure on workplace prevention and safety (2006-2013): a national-level analysis. Ann Ig. 2016 Sep-Oct;28(5):313-8. 42. Signorelli C OA, Gozzini A, Petrelli F, Tirani M, Zangrandi A, Zoni R, Florindo N La riforma costituzionale mancata e i possibili riflessi sulla sostenibilità del Servizio Sanitario Nazionale. Acta Biomed 2017;88:91-4. 43. Tediosi F, Gabriele S, Longo F. Governing decentralization in health care under tough budget constraint: what can we learn from the Italian experience? Health Policy. 2009 May;90(2-3):303-12. 44. Aimone Gigio L., Demetrio Alampi, Silvia Camussi, Giuseppe Ciaccio, Paolo Guaitini, Maurizio Lozzi, Anna Laura Mancini, Eugenia Panicara and Massimiliano Paolicelli (2018), La sanità in Italia: il difficile equilibrio tra vincoli di bilancio e qualità dei servizi nelle Regioni in Piano di Rientro, Questioni di economia e finanza, n.427, Banca d'Italia. 45. Cappellari L., De Paoli A., Turati G. (2016) Do market incentives for hospitals affect health services utilization? Evidence from prospective pay system-diagnosis related groups tariffs in Italian regions. Journal of the Royal Statistical Society - Series A, 179 (4): 885-905. 46. Cavalieri M., Ferrante L. (2016) Does fiscal decentralization improve health outcomes? Evidence from infant mortality in Italy. Social Science & Medicine, 164: 74-88. 47. De Belvis A.T., Ferrè F., Specchia M.L., Valerio L., Fattore G., Ricciardi W. (2012) The financial crisis in Italy: Implications for the healthcare sector. Health Policy, 106: 10- 16. 48. Di Novi C., Piacenza M., Robone S., Turati G. (2015), How Does Fiscal Decentralization Affect Withinregional Disparities in Well-being? Evidence from Health Inequalities in Italy, HEDG Working Paper Series, University of York, n° 23. 49. Ferrario C., Zanardi A. (2011) Fiscal decentralization in the Italian NHS: What happens to interregional redistribution?. Health Policy, 100 (1): 71-80.

Jo

ur

na

lP

re

-p

ro of

50. Francese M., Piacenza M., Romanelli M., Turati G. (2014) Understanding Inappropriateness in Health Spending: The Role of Regional Policies and Institutions in Caesarean Deliveries. Regional Science and Urban Economics, 49: 262-277. 51. Piacenza M., Turati G. (2014) Does Fiscal Discipline towards Sub-national Governments Affect Citizens' Well-being? Evidence on Health. Health Economics, 23(2): 199-224.

ro of

Fig. 1 Levels of LEA reached in the Italian Regions in year 2017 – (Source: Ministry of Health)

na

Jo

ur

2017

lP

re

-p

2013

Fig. 2 Migration of patients among the Italian regions for hospital care in 2013 and 2017 – (Source: Ministry of Health – Matrici di mobilità interregionale, anno 2017)

Tab.1 Trend of Italian Health Care expenditure 2007-2018: Absolute health care expenditure, % of GDP (Sources: Ministry of Economics)

Variation (year)

2007

Public Healthcare expenditure (billion euro) 101.7

2008

108.8

+6.9%

6.9%

2009

110.4

+1.5%

7.3%

2010

112.5

+1.9%

7.3%

2011

111.0

-1.4%

7.0%

2012

109.6

-1.3%

7.0%

2013

109.6

0%

2014

110.9

+1.2%

2015

111.2

+0.3%

2016

112.5

+1.2%

2017

113.6

+0.9%

6.6%

2018

115.4

+1.6%

6.6%

ro of 6.8% 6.8% 6.8% 6.7%

-p

lP na ur Jo

% of GDP 6.6%

re

YEAR