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Ministero della Salute The Health Care System in Italy General Directorate for Eu and Ministero della Salute The Health Care System in Italy General Directorate for Eu and International Relations Dr. Pietro Malara

Facts and policies of the National Health Care System • Born in 1978 (Law Facts and policies of the National Health Care System • Born in 1978 (Law 833) State level, regional level, local level (local health units) • Increased responsibility and autonomy of regional authorities (LD 502/1992) Local health units and main hospitals trasformed into Agencies managed by indipendent managers • Decentralisation process (LD 112/1998) and Modification of the National Health System structure and organization (DL 229/1999) Growing autonomy, responsibility and planning of the Regions on the objectives of prevention, treatment and rehabilitation 2

Ministero della Salute Health Devolution process • Fiscal Federalism (LD 56/2000) Changed the health Ministero della Salute Health Devolution process • Fiscal Federalism (LD 56/2000) Changed the health care financing system, taxation directly attributed to the Regions, national equalisation fund Establishment of a system that monitors and assesses the delivery of health care according to appropriate qualitative and quantitative indicators • Reform of chapter V of the Italian Costitution art. 117 Attributed to Regions the general legislative and administrative authority in basic sector of society The determination of the essential levels of services with regards to civil and social rights to be guaranteed in the whole country continues to pertain to the National Parliament and central Government

 National Health Care System Ministero della Salute Government Ministry of Health Conf. State-Regions National Health Care System Ministero della Salute Government Ministry of Health Conf. State-Regions 19 Regions Local H. Agencies 2 Autonomous Provinces Hospital Agencies Univ. Hosp. IRCCS 4

 National Health Care System Ministero della Salute General Practictioners Pharmacies Clinic and Laboratories National Health Care System Ministero della Salute General Practictioners Pharmacies Clinic and Laboratories Local H. Agencies Hospital Agencies University Hospitals, IRCCS Private Hospital Private clinic and Laboratories 5

Essential levels of health care – LEA Ministero della Salute ( DPCM 29 November Essential levels of health care – LEA Ministero della Salute ( DPCM 29 November 2001) All citizens are entitled to receive health care services included in the essential level at no cost at the point of access or upon payment of a small share for services that are not fully covered by the National Health System 1 Collective health care necessary 2 District health care appropriate 3 Hospital care homogeneous Agreement between the Central and Regional Governments of 8 August 2001 Resources for financing essential levels of health care were established and further responsabilities were given to the Region with regard to the organization of health services and to control health expenditures 6

1 Collective health care in life and working environments Including all prevention activities addressed 1 Collective health care in life and working environments Including all prevention activities addressed to the population and to individuals • Protection from the effects of pollution and industrial -accident risk • Veterinary public health • Food hygiene control • Prophylaxis for communicable diseases • Vaccination • Early diagnosis programs • Forensic medicine 7

2 District health care Including the health and social care services distributed throughout the 2 District health care Including the health and social care services distributed throughout the country • • Primary care Pharmaceutical assistance Local emergency Specialist day-hospital services Services for disabled and prostheses Home care services for the elderly and chronically ill people Mental health care services Semi-residential and residential structures for the elderly, disabled, terminal patients, substance abusers and alcoholics, HIV -positive person • Hydrothermal treatments 8

3 Hospital care • First-aid & emergency response • Ordinary hospitalisation • Day hospital 3 Hospital care • First-aid & emergency response • Ordinary hospitalisation • Day hospital and day surgery • Long term hospital stays • Rehabilitation hospital • Home based services provided by hospital staff • Blood and transfusion services • Tissue for grafts and trasplants 9

The role of the Ministry of Health The Ministry of health will have to The role of the Ministry of Health The Ministry of health will have to act as guarantor for the citizens to ensure that their rights are fully and uniformly respected and to make sure that regulations in place are properly implemented Complex system of indicators and parameters to monitor essential levels of health care delivered over the national territory National Information System gives data for monitoring essential levels of health care 10

Ministero della Salute Problems related to the system v Increasing citizens’ expectations v Population Ministero della Salute Problems related to the system v Increasing citizens’ expectations v Population ageing and consequent increase in service demand v Continuous cost rise determined by scientific and technological innovation v Restrictions imposed to public funding by commitments to comply with EU stability treaties 11

Ministero della Salute Objectives of the national health policy PREVENTION Promotion of the activities Ministero della Salute Objectives of the national health policy PREVENTION Promotion of the activities of : • Health education (tobacco and alcohol use, sedentary lifestyle, obesity, drugs, physical activity, road accidents ) • Primary prevention (vaccination) • Early diagnosis (cancer screening ) 12

Objectives of the national health Ministero della Salute policy Primary health care • Re-evaluation Objectives of the national health Ministero della Salute policy Primary health care • Re-evaluation of general pratictioners • Promotion of the territorial primary unit (UTAP) • Integrated networks for health care and social services for chronic patients, the elderly and the disabled Increase of the appropriateness of hospital services Reduction of inappropriate emergency admissions 13

Ministero della Salute Objectives of the national health policy HOSPITAL STRUCTURES • Redesigning hospital Ministero della Salute Objectives of the national health policy HOSPITAL STRUCTURES • Redesigning hospital networks • Centres of excellence • Appropriateness of hospital services (different settings of care: cost-effectiveness) Ordinary hospitalization Day-hospital Day-surgery 14

Ministero della Salute Objectives of the national health policy QUALITY OF HEALTH SERVICES • Ministero della Salute Objectives of the national health policy QUALITY OF HEALTH SERVICES • High-level permanent training in medicine ECM • implementation of clinical practice guidelines (evidence based medicine) • Clinical performance measures (es. bypass, hip prostesys) and reduction of the clinical risk • Health Tecnology Assessment • Reduction of disparities in health status and access to care 15

Ministero della Salute Objectives of the national health policy Health financing : • Attention Ministero della Salute Objectives of the national health policy Health financing : • Attention on aged population (funds for the non selfsufficient) • Increase of resources for prevention and district care • Integration across the public and private sectors • The proportion of GDP devoted to health is rising • Public health care expenditure trend: from 5. 1% of GDP(1996) to 6. 5% (2004) 16

NATIONAL HEALTH FINANCING Ministero della Salute 2004 2005 2006 84. 738 millions euro 91. NATIONAL HEALTH FINANCING Ministero della Salute 2004 2005 2006 84. 738 millions euro 91. 060. 94. 985 2007 96. 000 2008 2009 2010 2011 99. 042 102. 683 103. 945 106. 265 17

Current financing and current public health expenditure (values in millions euro) TABELLA 1 18 Current financing and current public health expenditure (values in millions euro) TABELLA 1 18

Costi Ricavi Risultato Tabella 2 Costi Ricavi Risultato Tabella 2

Costi Ricavi Risultato tabella 2 20 Costi Ricavi Risultato tabella 2 20

Ministero della Salute Main health achievement in Italy Life expectancy – male (EU 75 Ministero della Salute Main health achievement in Italy Life expectancy – male (EU 75 y) Life expectancy – female (EU 81, 2 y) 76 82, 1 Age stnd death rate (EU 257, 8) (per 100. 000 r. ) circolatory system 244, 2 Age stnd death rate (EU 184, 8) (per 100. 000 r. ) malignant neoplasms 178, 9 Infant death rate (per 1. 000 born) (EU 5) % newborn < 2500 gr. (EU 6, 6%) 4, 5 6, 4 % % smokers (EU 29, 3%) % obese (IMC > 30 ) 25 8, 9 21

Ministero della Salute The National health System in syntesis Local Health Agencies 195 Hospital Ministero della Salute The National health System in syntesis Local Health Agencies 195 Hospital Agencies Employees of the National Health System 102 656. 200 % physicians and dentists 15, 7% % nurses 40% Primary care pratictioners Patients for primary pratictioner Paediatricians Children for pediatrics Pharmaceutical prescriptions Beds in the rehabilitation institutes 46. 907 1. 100 7. 257 794 449 ml 16. 139 22

Ministero della Salute The National health System in syntesis Other public Hospitals 653 Accredited Ministero della Salute The National health System in syntesis Other public Hospitals 653 Accredited Private Clinics 531 Hospital ordinary beds in public health care 197. 465 per 1. 000 residents. 3, 65 Acute Accredited ordinary beds in private h. care per 1. 000 residents Acute Admissions in acute care (ordinary) Admissions rate (per 1. 000 r. ) – acute ordinary Average length of stay – acute care (days) 183. 083 48. 415 0, 88 33. 918 8. 879. 000 148 23 6, 7