Comparative Health Systems: Evaluating Italy using WHO Framework

This report provides an overview of the Italian healthcare system, known as Servizio Sanitario Nazionale (SSN), established in 1978. It evaluates the system's performance using the World Health Organization (WHO) framework, considering its organizational structure, funding, medical technologies, workforce, service delivery, and information research. The analysis highlights improvements in health indicators like life expectancy, but also points out regional funding disparities, inequalities in access, and challenges such as obesity and an aging population. The report discusses past reforms aimed at addressing financial constraints, corruption, and inefficiencies, including the introduction of regionalization, managerialism, and fiscal federalism. It also examines the Balduzzi decree and its impact on healthcare services. The report concludes by emphasizing the need for increased human resources, restructured service delivery, reduced corruption, and improved use of technology to ensure quality care in the face of future challenges.

Running head: COMPARATIVE HEALTH SYSTEM 1
Comparative Health System
Students Name
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COMPARATIVE HEALTH SYSTEM 2
Introduction and Background
Italy, the largest country in Europe, is listed among the countries that provide the best
quality health services by the World Health Organization. The Italian National Health Service
referred to as Servicio Sanitario Nazionale was started in the year 1978 with human dignity,
universal coverage, and solidarity as the golden rules. The health plan ensures that health
services are affordable or free inclusive of hospital visits, medication, lab work, and
consultations. The health care system is divided into three levels that is the national, regional and
local levels. The role of the national level is to ensure the achievement of the general objectives
and key principles of the Servizio Sanitario Nazionale. Regional governments via their regional
health departments play the role of ensuring that all the 16 health systems in the country receive
healthcare services via a network of local health authorities and both private and public
accredited hospitals.
Majority of the people living in the area have a high quality of life and standard of living
as a result of standard welfare measures and policies. Although some healthcare facilities are
considered useful in dealing with emergencies, some medical facilities are allegedly
overcrowded and lack adequate funds (Mackenbach, Karanikolos and McKee 2013, pp.1125-
1134). This essay seeks to explain the healthcare system of Italy using the World Health
Organization healthcare systems framework. It also aims at evaluating the performance of the
health system including both the past and current reforms using the available peer-reviewed
articles.

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Inclusion of examples
Italy's Organizational and structure is well organized and aims at providing universal
health care coverage at the point of delivery. Every region has the duty of providing health care
services to the patients. This means that the regions differ regarding the level of healthcare
provided. Although no law has specified patient rights and empowerment, they are present in the
Italian constitution as well as some pieces of legislationatic strategy (Nuti, Vola, Bonini, and
Vainieri 2016, pp.17-38).
Secondly, the health care system is mainly funded using both regional and national taxes
and co-payments from outpatient and pharmaceutical care. The role of government as outlined in
the Italian constitution is to decide the national statutory benefits package to be given to all the
people is all the regions. It is the responsibility of the two independent provinces and 19 regions
to plan and deliver health care services through the local health units. Majority of the regions
lack sufficient funds to run their day to day activities. This has a negative influence on the health
of the people often leading to increased mortality and morbidity rates. Increased economic crisis
and corruption has led to the mismanagement of funds and hence disrupting services (De Belvis
et al. 2012, pp.10-16).
Thirdly the healthcare system medical technologies and products have decreased over the
years due to cost-cutting measure that is taking place in the country. Regarding the infrastructure
in the hospital sector, in the year 2012, Italy had an estimated 3.4 hospitals per 1000 patients;
80% of which are set aside for patients in acute care. The number of CT scanners, MRI units,
and PET units have increased, the government has also developed e-health initiatives. There is a
great need of purchasing new medical products and technology that will help in the delivery of

COMPARATIVE HEALTH SYSTEM 4
healthcare. Present development should be keen on expanding electronic health records and
online services. As a result, there has been digitalization of medical certificates and prescriptions
(Marchildon 2013).
Fourthly, although there has been an increase in the health workforce, with an estimated
3.7 practising doctors per 1000 patients, there is need to grow the healthcare workforce to meet
the needs of the community. In the year 2010, SSN employed an overall 646 236 healthcare
personnel. 18.1% were technical staff, 70.2% were health staff, and 11.7% were administrative
staff. Among the employed health staff. 58.3% were nurses, 23.7% were physicians and the rest
18% were other health professionals (Marchildon 2013).
Fifthly, regarding service delivery, the ministry of health' responsibility is to ensure that
public health services are delivered at the national level. Programs such as screening and
immunization are prioritized. Also, pap tests, immunization programs, colorectal screening, and
mammography are offered nationally to the target population at free of charge. However, there is
a need to sensitize more people to utilise the services (Bordogna 2011, pp.411-423). Lastly,
concerning information and research, the country has failed to increase the use of communication
and information technologies in research to ensure that there is the provision of quality care.

COMPARATIVE HEALTH SYSTEM 5
Analysis of issues relevant to the healthcare system
Various health indicators have improved over the years; for instance, the country has a
life expectancy of an estimated 79.4, 84.5 years for men and women respectively in the year
2013 indicating that it is the second highest in the world. Italy has a vast difference in funding of
different regions with some regions having per capita expenditure of an estimated 17.7% above
the national average and 10.2% below. The healthcare system also introduced copayments for
drugs, ambulatory and outpatient care and diagnostics (Vainieri and Nuti 2011).
The health system has succeeded in prevention strategies such as vaccination. There is
also an advanced in the provision of care for patients with chronic conditions. However, there is
an increase in cases of obesity and overweight. Despite the fact Italy has a federal structure,
majority of the regions cannot fund healthcare using their resources (Nuti, Seghieri, and Vainieri
2013, pp.59-69). As a result, they rely on central transfers to recover for the differentiation in
local incomes (Turati 2013, pp. 47-66).
Although the main country objective is to ensure equity in the access of health care, the
country suffers severe inequalities in the provision of healthcare across people with different
socioeconomic status. Some of these inequalities arise from the difference in population wealth
and efficiency of healthcare mainly in the southern and northern regions in Italy. In the recent
years, there has been a decline in the level of satisfaction of consumers (Pavolini and Vicarelli
2012, pp.472-488).
There is no increased use and access of information and technology among the healthcare
providers. There is need to improve both technology and information, for instance, the healthcare

COMPARATIVE HEALTH SYSTEM 6
professionals in Italy need to access online medical resources to enhance their knowledge about
specific diseases and new methods of treating the disease as wells the use of new medical
equipment. The healthcare professionals need to use the available medical information to ensure
that they meet the patients' needs and that they receive the right care (Anon 2017).
Future challenges and emerging issues that may affect Italy’s healthcare system include
technic, ethical and economic factors. The health system is likely to face increasing financial
constraints and hence affecting the delivery of services (Karanikolos et al. 2013, pp.1323-1331).
The country is also expected to experience a situation where patients wait for an extended period
to receive services such as outpatient and diagnostic services. This is due to the inequitable
distribution of local health facilities among different socioeconomic groups, regions, and gender.
Lessons learned from other countries in the European region is that it is essential to
increase human resources for health and restructure the delivery of healthcare services. It is also
essential to ensure that there are reduced corruption cases in the healthcare system. Another
lesson learnt is that the majority of the funds should not be spent on the healthcare providers,
instead, they should be channelled to the delivery of healthcare.
Relevant data and literature
Italy’s healthcare system has undergone numerous reforms. The establishment of the
second reform of SSN took place in the year 1978 in place of a system that relied on much social
health Insurance. This was the initial significant health care reform to occur in Italy during the
post-second world war period. Although the SSN system was put into law entirely in the 1980s,
the weaknesses of the system became evident in the same year (Marchildon 2013). Firstly, there
was a lack of expertise to ensure the proper functioning of the Healthcare system. Secondly, the

COMPARATIVE HEALTH SYSTEM 7
central government was unable to exercise control over the finances. Thirdly, there was an
endless politicization of the SSN institutions. Finally, there was a lack of proper management
systems (Coulter and Jenkinson 2015, pp.355-360).
Italy was hit by high debt and economic crisis hindering the country from meeting the
Maastricht criteria on recommended European monetary union. Also, several corruption scandals
led to the collapse of Italy’s central governing parties. However, a new government was formed
and managed to decrease public expenditures in many sectors such as the healthcare sector. In
this moment of opportunity, the SSN second reform was quickly approved. The reform
incorporated regionalization, managerialism, quasi-market for professional care and the
withdrawal of the National Health Service (Francese and Romanelli 2014, pp.117-132).
The third health-care reform was put into law in the year 1999. The reform emphasized
the SSN health system was universal and other the control of the government. In the year 2001, a
constitutional reform was invented and comprised the overall delivery of fiscal federalism. It also
included implementing the rule that all the levels of Italy’s government including regions,
municipalities, and provinces should at all times utilize the money they collect from their
respective constituencies and to some extent receive resources that show their respective
constituencies’ collection to the government taxes through corporate, individual and other taxes.
Therefore this critical healthcare reform includes an extensive recreation of the fiscal system of
Italy and hence making it more dependent and decentralized on regional contexts. It also
includes the proper distribution of resources across the regions to ensure that all citizens receive
essential services (Marchildon 2013). Since all the regions must deliver and organise health care
services, putting the reform into law will have a positive effect on the issuance of resources and
the money available to the local health systems (Costa-Font and Greer 2016).

COMPARATIVE HEALTH SYSTEM 8
A huge step in the enactment of a structural law for Fiscal federalism was taken in 2009.
The framework explained the processes to make sure that there is proper coordination between
the different levels of the government. It also outlined the principles to be used in the
redistribution of resources to the standards of government with the lowest own revenues. The
essential for the proper funding of the health care services is to ensure equalization fund through
which regions with the lowest revenue collection are targeted to ensure that they receive quality
health care (Lynch 2014, pp.380-388).
Both the New resource allocation framework, as well as the Equalization fund, have not
been put into use. While nine enforcing decrees were put into law by the parliament, a special
parliamentary in the year 2013 established that the reform was not complete. Many critical
aspects had been deferred while others had not been tackled. Majority of political factors are
responsible for this; firstly, there has been political instability due to three changes of
government from 2013. Secondly, contemporaneous amendments that collide with the idea of the
fiscal federalism framework such as eliminating provinces have prevented its implementation.
The implementation of the framework relies on the future political situation (Petmesidou,
Pavolini and Guillén 2014, pp.331-352).
In 2012 there were efforts to initiate the most comprehensive reform of Italy’s healthcare
system referred to as Balduzzi decree. In 2001, the original benefits package was seriously
revised for the first time inclusive of health services such as epidurals at the time of childbirth
and the treatment of about 110 rare diseases. Also, doctors were encouraged to perform their
activities within the SSN healthcare facilities. A decision was also arrived at that primary care
should be restructured into groups of qualified healthcare workers to ensure they give 24-hour
coverage. Stronger regulations were also made on minors engaging in alcohol and smoking

COMPARATIVE HEALTH SYSTEM 9
activities. Furthermore, there was the introduction of policies to reduce pharmaceutical costs.
Although the parliament passed the Balduzzi reform in 2013, it has not been implemented due to
political instability (Marchildon 2013).
Amid increasing political instability, there have been central cost containment policies.
On the one hand, they help in ensuring control over the overall spending and ensuring that
regions do not spend unreasonably. On the other, they target the sources of regional expenditure
with the use of measures on recruitment, payment of health personnel and standards of hospital
care. For instance, currently, there is a policy aiming at reducing the pharmaceutical spending
using methods such as reexamining the percentage of the overall price concerning
pharmaceutical companies, pharmacies, and wholesalers (Blendon, Leitman, Morrison and
Donelan 2011 pp.185-192).
Other measures include continuous cutback of the cap on local pharmaceutical spending
in community and primary health care as well as decreasing the price of particular drugs
Satisfaction with health systems in ten nations. Another example is the cutting down of costs in
purchasing medical equipment. This measure was strengthened in 2012 with an aim on ensuring
that all the SSN contracts are acquired using standard prices. In addition, the government has
encouraged regions to cut on their spending on health professionals (Levaggi and Menoncin
2013, pp.725-737).

COMPARATIVE HEALTH SYSTEM 10
Conclusion
Italy's healthcare system has made enormous progress in delivering quality health care to
all people irrespective of the social class and gender. However, much can be done to address all
the challenges the healthcare system is facing. For instance, the country can ensure that there is
an improvement in the efficiency of local health facilities as well as increased prevention of
diseases.

COMPARATIVE HEALTH SYSTEM 11
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