Italy: Health System Review

This analysis of the Italian health system reviews recent developments in organization and governance, health financing, health care provision, health reforms and health system performance. Italy has a regionalized National Health Service (SSN) that provides universal coverage largely free of charge at the point of delivery, though certain services and goods require a co-payment. Life expectancy in Italy is historically among the highest in the EU. However, regional differences in health indicators are marked, as well as in per capita spending, distribution of health professionals and in the quality of health services. Overall, Italy's health spending per capita is lower than the EU average and is among the lowest in western European countries. Private spending has increased in recent years, although this trend was halted in 2020 during the coronavirus disease 2019 (COVID-19) pandemic. A key focus of health policies in recent decades was to promote a shift away from unnecessary inpatient care, with a considerable reduction of acute hospital beds and stagnating overall growth in health personnel. However, this was not counterbalanced by a sufficient strengthening of community services in order to cope with the ageing population's needs and related chronic conditions burden. This had important repercussions during the COVID-19 emergency, as the health system felt the impact of previous reductions in hospital beds and capacity and underinvestment in community-based care. Reorganizing hospital and community care will require a strong alignment between central and regional authorities. The COVID-19 crisis also highlighted several issues pre-dating the pandemic that need to be addressed to improve the sustainability and resilience of the SSN. The main outstanding challenges for the health system are linked to addressing historic underinvestment in the health workforce, modernizing outdated infrastructure and equipment, and enhancing information infrastructure. Italy's National Recovery and Resilience Plan, underwritten by the Next Generation EU budget to assist with economic recovery from the COVID-19 pandemic, contains specific health sector priorities, such as strengthening the country's primary and community care, boosting capital investment and funding the digitalization of the health care system.Copyright World Health Organization 2022 (acting as the host organization for, and secretariat of, the European Observatory on Health Systems and Policies).

Primary health care reforms in Slovenia: leveraging existing structures to expand care : Pia Vracko

Primary health care (PHC) in Slovenia is delivered mainly by a network of 63 public community-based primary health care centres (CPHCs), serving as entry points to the health system. Here, multidisciplinary teams provide an array of preventative, diagnostic, therapeutic, palliative, and health promotion services under one roof. Since 2011, several reforms in PHC highlight integrated care. A national scale-up of Family Medicine Practices is underway, where all family medicine teams include a 0.5 FTE registered nurse to improve prevention, early diagnosis and care coordination of chronic patients. Health promotion centers (HPCs) are being introduced in CPHCs to support people in healthy lifestyle, with currently 28 HPCs managed by CPHCs and supported operationally by the National Institute of Public Health. New mental health centers facilitate access to comprehensive mental health care. In 2020, dedicated temporary COVID-19 units in CPHCs played a key role in treating mild/moderate cases and shielding hospitals from overburden. Regarding implementation, pilots have been critical to creating a strong evidence base to enable sustainable (sometimes external) financing, while innovations capitalize on existing links between Slovenia's primary care and public health functions and the Ministry of Health for governance and the flexibility of the multidisciplinary, multiple-practice care model represented by CPHCs. Though this has eased their initial introduction into existing structures, challenges remain. These include dissatisfaction among family physicians due to high administrative burden and an outdated CPHC governance model that limits managers’ authority as well as workforce shortages in public health and primary care. Financial incentives, task shifting, and adjustments to education and training have been used to mitigate these issues. Slovenia's experience may serve as a case study for countries interested in improving their primary healthcare services.

Do EU countries comply with the right to healthcare under the UN Convention on the Rights of the Child? : Cristina Hernandez Quevedo

Children's health status varies within and between European countries. To what extent this is associated with access barriers to timely and effective care children may face is not yet fully understood. Article 24 of the UN Convention on the Rights of the Child (UNCRC) guarantees a fundamental right to healthcare for all children, regardless of their legal status in terms of citizenship, residence, or insurance. Using information contained in the Health Systems in Transition reports produced by the European Observatory on Health Systems and Policies, additional relevant literature, and responses to a structured questionnaire filled out by key informants from all 27 EU MS and the United Kingdom, we evaluated whether European countries comply with the specific obligations that can be drawn from the UNCRC. While all countries considered have ratified the UNCRC, only four countries have included a specific disposition in their legislation that establishes an unconditional, universal right to health services for all children living in their territory. In other countries, the fragmented way of defining children's access rights can create gaps in legislation which can leave certain groups of children without coverage. Children with irregular residence are the most vulnerable group when it comes to eligibility problems, but other groups of children may also fall between the cracks or be only entitled to restrict-ed or conditional access to health care. These insights show that international treaties, such as the UNCRC, can help monitor health coverage and ensure that basic human rights to health services are guaranteed in times of crisis, such as the Covid-19 pandemic and the Ukraine Displacement, but may be insufficient without concrete transposition into national legislative frameworks.

A cross-country comparison on providing health services effectively during the first wave of COVID-19

At the onset of the COVID-19 pandemic, health care providers had to abruptly change their way of providing care in order to simultaneously plan for and manage a rise of COVID-19 cases while maintaining essential health services. Even the most well-resourced health systems faced pressures from new challenges brought on by COVID-19, and every country had to make difficult choices about how to maintain access to essential care while treating a novel communicable disease. Using the information available on the HSRM platform from the early phases of the pandemic, we analyze how countries planned services for potential surge capacity, designed patient flows ensuring separation between COVID-19 and non-COVID-19 patients, and maintained routine services in both hospital and outpatient settings. Many country responses displayed striking similarities despite very real differences in the organization of health and care services. These include transitioning the management of COVID-19 mild cases from hospitals to outpatient settings, increasing the use of remote consultations, and cancelling or postponing non-urgent services during the height of the first wave. In the immediate future, countries will have to continue balancing care for COVID-19 and non-COVID-19 patients to minimize adverse health outcomes, ideally with supporting guidelines and COVID-19-specific care zones. Many countries expect to operate at lower capacity for routinely provided care, which will impact patient access and waiting times. Looking forward, policymakers will have to consider whether strategies adopted during the COVID-19 pandemic will become permanent features of care provision.

Effective contact tracing and the role of apps: lessons from Europe. (Special Issue: COVID-19 health system response.)

Contact tracing is an essential tool to support the transition back to normal life during the COVID-19 pandemic. This article explores how 31 countries operate contact tracing, using data extracted from the COVID-19 Health Systems Response Monitor (HSRM). Two main approaches emerge: centralised (led by one national agency) and decentralised (at regional/district level). In most cases, trained staff conduct phone interviews, and many countries have moved to strengthen the capacity of tracing teams. Further, contact tracing apps are being developed and implemented, although some difficulties related to privacy concerns have arisen, necessitating more transparency on how data are collected.

How are countries supporting their health workers during COVID-19? (Special Issue: COVID-19 health system response.)

Health workers have been at the forefront of treating and caring for patients with COVID-19. They were often under immense pressure to care for severely ill patients with a new disease, under strict hygiene conditions and with lockdown measures creating practical barriers to working. In this article we consider measures that countries have put in place to support health workers and enable them to do their job. We show that countries have implemented a range of measures, from mental health support, financial bonuses and practical support such as free accommodation and transport. The effectiveness of these initiatives should be evaluated to inform future crisis responses and strategies for health workforce development.

What strategies are countries using to expand health workforce surge capacity during the COVID-19 pandemic? (Special Issue: COVID-19 health system response.)

Finding ways to increase the surge capacity and flexibility of the health workforce has been fundamental to delivering an effective COVID-19 response. This article explores the strategies that 44 countries in Europe plus Canada have taken to maintain and increase the availability of health workers using data from the COVID-19 Health System and Response Monitor. We show that all countries have used a variety of strategies to repurpose and mobilise the existing health workforce, while some have also augmented capacity by utilising foreign-trained or previously retired or inactive health professionals, medical and nursing students and volunteers.

Restarting more routine hospital activities during COVID-19: approaches from six countries. (Special Issue: COVID-19 health system response.)

During the COVID-19 pandemic, hospitals face the concurrent challenges of maintaining routine services while attending to COVID-19 patients. This article shares approaches taken in six countries to resume hospital care after the first wave of the pandemic by surveying country experts and using data extracted from the COVID-19 Health Systems Response Monitor (HSRM). Four strategies were observed in all six countries: prioritisation or rationing of treatments, converting clinical spaces to separate patients, using virtual treatments, and implementing COVID-19 free hospitals or floors. Clear guidance about how to prioritise activities would support hospitals in the next phases of the pandemic.

Compensating healthcare professionals for income losses and extra expenses during COVID-19. (Special Issue: COVID-19 health system response.)

COVID-19 has affected the incomes of some health professionals by reducing demand for care and increasing expenditures for treatment preparedness. In a survey of 14 European countries, we found that most countries have incentivised substitutive e-health services to avoid loss of income. Health professionals have also received financial compensation for loss of income either through initiatives specifically designed for the health sector or general self-employment schemes, and have either been reimbursed for extra COVID-19-related expenditures such as personal protective equipment (PPE) or had these provided in kind. Compensation is generally funded from health budgets, complemented by emergency funding from government revenue.