Italy Health System Reforms and Challenges

“More than a third of Italy’s RRP budget dedicated to health will be directed to support the digital transformation of healthcare services, including the establishment of a fully integrated and interoperable electronic patient record system, while about a fourth will be used to finance various hospital equipment upgrades (Figure 24). More than 18 % of the health budget will be used to strengthen community-based outpatient clinics and community hospitals. To boost the future supply of medical professionals and resolve the ‘training bottleneck’ that characterises Italy’s medical workforce training pipeline (see Section 4), about 4 % of the budget will be used to finance postgraduate residency programmes to train 2 700 GPs and 4 200 medical specialists.

“These investments will be complemented by the rollout of the EU Cohesion Policy 2021-27 programming, which will see Italy invest a total of EUR 3.46 billion in its healthcare system. Approximately 57 % of this amount will beco-financed by the EU. Specifically, EUR 2.25 billion from the European Social Fund Plus (ESF+) will fund a range of measures aimed at enhancing the accessibility, quality and resilience of healthcare services in the less developed regions of the country, focusing on health workforce development and the elimination of barriers to access for vulnerable populations. Furthermore, EUR 1.2 billion from the European Regional Development Fund (ERDF) will be used for the acquisition of medical equipment and the modernisation of healthcare facilities within the Italian NHS.⁴.”

Source: OECD/European Observatory on Health Systems and Policies (2023), Italy: Country Health Profile 2023, State of Health in the EU, OECD Publishing, Paris/European Observatory on Health Systems and Policies, Brussels.

“While no major reforms have changed the fundamental structure of the SSN over the last 15 years, most regional health systems have been consolidating their governance, planning and delivery mechanisms. At the national level, the government has brought about important changes in the areas of prevention and hospital care as well as in rationalizing the national benefits package (LEA). Specific attention has also focused on financial probity, with the introduction of a special regime for regions that overshoot their health budget and/or do not deliver the guaranteed core services of the national benefits package.”

Source: de Belvis AG, Meregaglia M, Morsella A, Adduci A, Perilli A, Cascini F, Solipaca A, Fattore G, Ricciardi W, Maresso A, Scarpetti G. Italy: Health system review. Health Systems in Transition, 2022; 24(4): pp.i–203.

“A Ministerial Decree targeting hospital care was issued by the Ministry of Health in 2015 (Ministerial Decree 70/2015). This major and ambitious planning document took a long period to develop, during which time there was no detailed planning of the hospital system. The document sets standards for the main characteristics of SSN [National Health Service] and private-accredited hospitals and their activities; for example, it sets a minimum number of beds each hospital should have and classifies hospitals into different categories. It indicates that regions should aim for 90% hospital bed occupancy rates, 160 admissions per 1,000 patients and 3.7 hospital beds per 1,000 inhabitants: 3.0 for acute care and 0.7 for rehabilitation or medical long-term care. These figures are calculated using detailed standards for each specialty, using national experience and international evidence. These standards aim to incentivize the use of ambulatory care for appropriate treatments (e.g. for cataract surgery) and reduce inappropriate admissions (e.g. those of frail patients without an acute episode who should be cared for in other settings). The most innovative element of Ministerial Decree 70/2015 relates to the use of volume standards for planning hospitals’ sizes and their reconfiguration (see below). Based on systematic reviews on the relationship between volumes and outcomes, the Ministerial Decree sets minimum standards for specific surgical procedures, generally expressed as a number of cases per year (e.g. for cardiology at least 100 and 200 cases per year should be treated for acute myocardial infarction and coronary artery bypass graft, respectively).

“These provisions face two major constraints, one institutional and the other geographical. The difference in population size among regions limits the full implementation of the decree without formal agreements between regions for the different categories of hospitals (see Chapter 5 and section 4.3). Moreover, the decentralized nature of the SSN makes these agreements sometimes difficult: the geographical constraints mean that some villages can be more than a 45 minutes drive away from the closest hospital, very often with limited means of public transport. It is not surprising, then, that reorganizing hospital care for these communities is challenging and that Ministerial Decree 70/2015 faces strong resistance from the population and their political representatives as hospitals are staffed with local people and they are important political and social symbols for local communities (Healy & McKee, 2002). For this reason, the decree also leaves open the option of maintaining small hospitals that do not comply with the targets presented above (e.g. because they are in the minor islands or mountain areas) and envisions the development of community hospitals, i.e. small facilities providing low and medium intensity care with no more than 40 beds.”

“The future of the health-care system mainly depends on the future of the country’s economy. If Italy overcomes the structural crisis and starts growing, cost-containment measures can be relaxed and the SSN [Italy’s National Health Service] can receive enough resources to meet the expectations of high quality and universal coverage. Overall, compared to other European countries, the SSN is already rather parsimonious; thus, longer periods of hard cost-containment policies may harm the delivery system and may induce popular calls for change. To deal with these serious fiscal constraints, the SSN may benefit from a better definition of the specific content of the benefit package it guarantees to citizens (mainly a more detailed definition of the LEA). A narrower definition of the SSN benefit package may help to concentrate resources in the most effective and cost-effective areas, maintain high quality in these essential services and, at the same time, provide space for complementary insurance schemes.

“Moving to the way the system is organized and services are delivered, three main issues deserve to be highlighted. The first concerns the relationship between politics and top management. The 1992/93 reforms limited the role of professional politicians in running SSN organizations and promoted the role of general managers. Indeed SSN organizations have experienced increasing professionalism at management level. Nevertheless, the appointment of general managers, health directors and administrative directors still appears to be mainly driven by local and political considerations. Interestingly, as general managers in the SSN tend to work almost exclusively in their region of residency, a national market for general managers has yet to materialize. Appointments based on political affiliation and without adequate consideration of professional qualities are frequent. These appointments limit the potential of general management as it makes it very difficult to manage ambitious tasks such as the closure of small hospitals, the development of new integrated systems of care or the redesign of hospitals.”

Source: Ferré F, de Belvis AG, Valerio L, Longhi S, Lazzari A, Fattore G, Ricciardi W, Maresso A. Italy: Health System Review. Health Systems in Transition, 2014, 16(4):1–168.

“A second major issue concerns primary care, which in Italy is still mainly based on solo-practice GPs or general paediatricians. This part of the SSN [National Health Service] has been only modestly addressed by reforms and policy initiatives, mainly aimed at promoting its organizational development based on GPs, paediatricians, nurses and other professionals working together in primary care teams. There is wide agreement that such models should be widely adopted. However, they require substantial changes that need to be well promoted, incentivized and managed. It is unlikely that new legislation will suffice to make these changes happen on the ground, also due to the lack of fresh resources to motivate professionals. More likely, regions and ASLs, adequately supported by regional and national frameworks, will be the key actors to manage changes in order to make primary care more inter-professional and collaborative than it is now. But again, different institutional and managerial capacities may result in very heterogeneous solutions across regions.”

Source: Ferré F, de Belvis AG, Valerio L, Longhi S, Lazzari A, Fattore G, Ricciardi W, Maresso A. Italy: Health System Review. Health Systems in Transition, 2014, 16(4):1–168.

“A third major issue concerns integration, de-integration and re-integration. Originally, the SSN [National Health Service] was designed to be a very integrated system with virtually all services under the control of Local Health Units (the former name of the ASLs). Partly due to the attempt to promote a quasi-market, partly due to the desire to better recognize the role of private providers and partly because the idea of the purchaser–provider split inspired Italian policy making, from the mid-1990s the SSN was partly de-integrated, mainly by making hospitals independent of ASLs. Currently, however, most regional policies seem to have returned to integration, namely through the re-attribution of some hospitals to ASLs, the concentration of purchasing activities in regional or supraorganizational entities and the enlargement of the size of ASLs. In addition, most regions have strengthened control over their providers. Overall, in the last 10 years regional authorities have increased their grip over provider organizations, which in turn, have lost most of their organizational autonomy. This trend towards re-integration is probably due to the general conditions of austerity and the search for savings. But at the same time, it is also due to the search for better integrated care pathways that can overcome barriers deriving from the involvement of different organizations in treating the same case. It is clear that patients increasingly need a variety of providers working in a co-ordinated way and that such co-ordination is essential to ensure quality of care as well as cost-containment. But how to experiment, evaluate and disseminate good practices in this respect is more an issue of policy design developed from the bottom, rather than the results of top-down policies that reduce the number of SSN organizations by making them larger.”

Source: Ferré F, de Belvis AG, Valerio L, Longhi S, Lazzari A, Fattore G, Ricciardi W, Maresso A. Italy: Health System Review. Health Systems in Transition, 2014, 16(4):1–168.

Italy: Health System Reforms and Challenges - National Policies - World Health Systems Facts

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Page last updated April 21, 2025 by Doug McVay, Editor.