Italy: #30 in the 2022 World Index for Healthcare Innovation
Italy’s socialized healthcare system performs mediocre-to-poorly across the board.
By Gregg Girvan, Grant Rigney, and Avik Roy
Introduction
Italy ranked 30th overall in the 2022 World Index of Healthcare Innovation, down from 28th in 2021 and 29th in 2020. Italy underperformed across all four dimensions — ranking 22nd for Quality, 30th for Choice, 27th for Science and Technology, and 26th for Fiscal Sustainability. While Italy’s healthcare costs are relatively low compared to its European peers, it offers patients limited choices for new therapies and primary care providers. For instance, once Italian citizens select a primary care provider, they cannot change that doctor for a year.
Background
The Italian health care system goes back to 325 A.D., when, following the First Council of Nicæa, the Roman Empire built a hospital in every cathedral town. Italy’s modern-day socialized health system began with the creation of the Italian National Health Service (Servizio Sanitario Nazionale, or SSN) in 1978. The SSN divides into three jurisdictions at the national, regional, and local levels — including 19 regions and two autonomous provinces. Each region enjoys significant autonomy in the distribution of its healthcare services, with the central government controlling the distribution of tax revenue to the areas to provide care.
Ultimately, corporate and value-added taxes finance Italy’s single-payer system alongside general and regional tax revenue. Total healthcare expenditures for Italy’s 59.1 million residents are around 9.5 percent of national GDP. Public funding accounted for 74.2 percent of total health spending in 2018, with private health insurance accounting for approximately 1 percent. For Italians, public health insurance covers the “essential levels of care” (livelli essenziali di assistenza, or LEA), akin to the “essential health benefits” seen in other developed countries. For services outside of these LEAs, private health insurance covers these elective procedures. Private insurance offers more comprehensive primary care provider options and offers additional amenities in hospitals for approximately 6 million people, just under 10 percent of the population.
Hospitals in Italy are primarily public, representing 80 percent of all hospital beds. A smaller contingent of private hospitals contains the other 20 percent of beds. Public hospitals are either managed directly by local health units or operate as semi-independent public enterprises. Under these arrangements, hospital-based physicians are salaried and are often discouraged from treating patients with private insurance. Public-hospital physicians are prohibited from treating patients in a private hospital; if they see private patients in a public hospital, they must pay a portion of their extra income to that hospital.
Several national directorates oversee specific areas of healthcare to control national costs, with several holding key roles in cost containment. The National Committee for Medical Devices develops cost-benefit analyses and outlines reference pricing for medical devices. Similarly, the National Pharmaceutical Agency analyzes and sets prescription drug prices and reimbursement rates. Payment rates for hospital and outpatient specialist care are determined regionally, with national rates serving as references.
Quality
Italy ranked 22nd in Quality, driven by poor performance in pandemic preparedness and response (27th) and patient-centered care (27th). The COVID-19 pandemic’s effects devastated Italy, primarily due to the country’s aging hospital infrastructure and an older patient population — the latter due to Italian citizens’ remarkably long lifespan. Additionally, Italy’s Infrastructure ranked below the median at 20th. However, Italy ranked above the median (4th) for measures of preventable disease.
Choice
Italy ranked 30th in Choice. Italy ranked below the median in affordability of health insurance (23rd), access to new medical treatments (21st), and ranked second-to-last for freedom to choose healthcare services (31st).
Science & Technology
Italy performed below average for Science and Technology (27th). In particular, its adoption of health IT remained low and ranked 30th in health digitization. Similarly, Italy’s contribution to medical advances and scientific discoveries ranked 17th and 22nd, respectively.
Fiscal Sustainability
Italy ranked 26th for Fiscal Sustainability. Admittedly, the fiscal health of the Italian healthcare system is an open question. While the nation ranked 9th in growth of health spending because healthcare’s share of GDP has plummeted over the last ten years, Italy ranks 30th in national solvency. Like Greece and Spain, the economic effects of the global recession and the COVID-19 pandemic linger in the Italian economy.
