JANUARY

The Italian Health Care System, 2015
Andrea Donatini
Emilia-Romagna Regional Health Authority
What is the role of government?
The Italian National Health Service (Servizio Sanitario Nazionale) is regionally based and organized at the
national, regional, and local levels. Under the Italian constitution, responsibility for health care is shared by the
national government and the 19 regions and 2 autonomous provinces. The central government controls the
distribution of tax revenue for publicly financed health care and defines a national statutory benefits package
to be offered to all residents in every region—the “essential levels of care” (livelli essenziali di assistenza). The
19 regions and two autonomous provinces have responsibility for the organization and delivery of health
services through local health units. Regions enjoy significant autonomy in determining the macro structure of
their health systems. Local health units are managed by a general manager appointed by the governor of the
region, and deliver primary care, hospital care, outpatient specialist care, public health care, and health care
related to social care.
Who is covered and how is insurance financed?
Publicly financed health care: The National Health Service covers all citizens and legal foreign residents.
Coverage is automatic and universal. Since 1998, undocumented immigrants have access to urgent and
essential services. Temporary visitors can receive health services by paying for the costs of treatment.
Public financing accounted for 78 percent of total health spending in 2013, with total expenditure standing
at 9.1 percent of GDP (OECD, 2014). The public system is financed primarily through a corporate tax
(approximately 35.6% of the overall funding in 2012) pooled nationally and allocated back to regions, typically
the source region (there are large interregional gaps in the corporate tax base, leading to financing inequalities),
and a fixed proportion of national value-added tax revenue (approximately 47.3% of the total in 2012) collected
by the central government and redistributed to regions unable to raise sufficient resources to provide the
essential levels of care (Ministero dell’Economia e delle Finanze, 2012).
Regions are allowed to generate their own additional revenue, leading to further interregional financing
differences. Every year the Standing Conference on Relations between the State, Regions, and Autonomous
Provinces (with the presidents of the regions and representatives from central government as its members) sets
the criteria (usually population size and age demographics) to allocate funding to regions. Local health units are
funded mainly through capitated budgets.
The 2008 financial law established that regions would be financed through standard rates set on the basis
of actual costs in the regions considered to be the most efficient. Established in legislation, this policy is not
yet operating.
Since the National Health Service does not allow members to opt out of the system and seek only private care,
substitutive insurance does not exist. At the same time, complementary and supplementary private health
insurance is available (see below).
Privately financed health care: Private health insurance plays a limited role in the health system, accounting
for roughly 1 percent of total spending in 2009. Approximately 15 percent of the population has some form of
private insurance, which generally covers services excluded under the LEA, to offer a higher standard of comfort
and privacy in hospital facilities, and wider choice among public and private providers. Some private health
insurance policies also cover copayments for privately provided services, or a daily rate of compensation
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