How do international economic policies impact on the ability of countries like France and Italy to ensure universal coverage for healthcare services???Ch9GlobalHealthSys

9.1 INTRODUCTION

Italy, officially known as the Italian Republic, covers an area of 301,225 square km. (116,303 square miles) and is bordered by France, Switzerland, Austria, and Slovenia. Known by its boot-like shape, Italy is equivalent to the size of Georgia and Florida combined. Italy became a democratic republic in 1946 a few years after the fall of the fascist regime in WWII. Italy has OECD status and is a founding member of the European Union (EU). According to the Central Intelligence Agency (CIA), the literacy rate in Italy is high, at 99% (CIA, 2011). In 2011, the population of Italy was estimated at 60.6 million. Italy is an industrialized country and is ranked as the world’s seventh largest market economy (U.S. Department of State Background Note, 2011). However, Italy is struggling with an exceedingly high public debt and fiscal deficit. The proportion of the population under 15 is 14% and the proportion of the population above the age of 60 years is 24% (WHO 2004). The main language used in the country is Italian. The largest ethnic group is Italian. The largest religious group is Roman Catholic.

Indicators for infant mortality and life expectancy suggest that, “Italy has a very healthy population” (Maio & Manzoli, 2002, p. 301). The total estimated infant mortality rate per 1,000 live births is 3:38 deaths; (male: 3.59 deaths/1,000 live births; female: 3.16 deaths/1,000 live births) (CIA, 2011). The estimated life expectancy for men is 79.16 and it is 84.53 for women (CIA, 2011). Adult mortality for men is 91:1,000 and for women, 47:1000 (World Health Organization, 2006). Demographic concerns over the past two decades involve Italy’s persistent low fertility rates. Current estimates indicate Italy’s total fertility rate as 1.39, resulting in birth rates falling below replacement levels of 2.1 children per woman (CIA, 2011; Maio & Manzoli, 2002). Italy’s population challenges include a decline in the younger age groups and a rapidly aging population.

9.1 INTRODUCTION

Italy, officially known as the Italian Republic, covers an area of 301,225 square km. (116,303 square miles) and is bordered by France, Switzerland, Austria, and Slovenia. Known by its boot-like shape, Italy is equivalent to the size of Georgia and Florida combined. Italy became a democratic republic in 1946 a few years after the fall of the fascist regime in WWII. Italy has OECD status and is a founding member of the European Union (EU). According to the Central Intelligence Agency (CIA), the literacy rate in Italy is high, at 99% (CIA, 2011). In 2011, the population of Italy was estimated at 60.6 million. Italy is an industrialized country and is ranked as the world’s seventh largest market economy (U.S. Department of State Background Note, 2011). However, Italy is struggling with an exceedingly high public debt and fiscal deficit. The proportion of the population under 15 is 14% and the proportion of the population above the age of 60 years is 24% (WHO 2004). The main language used in the country is Italian. The largest ethnic group is Italian. The largest religious group is Roman Catholic.

Indicators for infant mortality and life expectancy suggest that, “Italy has a very healthy population” (Maio & Manzoli, 2002, p. 301). The total estimated infant mortality rate per 1,000 live births is 3:38 deaths; (male: 3.59 deaths/1,000 live births; female: 3.16 deaths/1,000 live births) (CIA, 2011). The estimated life expectancy for men is 79.16 and it is 84.53 for women (CIA, 2011). Adult mortality for men is 91:1,000 and for women, 47:1000 (World Health Organization, 2006). Demographic concerns over the past two decades involve Italy’s persistent low fertility rates. Current estimates indicate Italy’s total fertility rate as 1.39, resulting in birth rates falling below replacement levels of 2.1 children per woman (CIA, 2011; Maio & Manzoli, 2002). Italy’s population challenges include a decline in the younger age groups and a rapidly aging population.

9.3 STRUCTURE

Italy’s healthcare system is region-based and highly decentralized. The health service structure encompasses three levels: national (state), regional, and local. The Ministry of Health operates as the central organization of NHS and is responsible for healthcare planning, healthcare financing, and ensuring the uniform delivery of the benefits package. The regions are responsible for ensuring access to the benefits package through their regional health departments, local healthcare agencies (LHAs), and public and private health services providers. Regional governments are aimed at identifying the unique needs of their populations. Due to decentralization, the regions have considerable autonomy in managing their own budgets. This means they are also “required to fund any deficit that might occur from their own resources” (Maio & Manzoli, 2002, p. 302).

At the local level, LHAs are geographically situated throughout the regions and provide service to specific populations. LHAs are in charge of providing a coordinated, comprehensive level of care through their own facilities or through other accredited private providers. Units of care called hospital trusts, as well as university-centered research hospitals provide secondary and tertiary care (Maio & Manzoli, 2002).

Italy has one of the highest numbers of physicians on record worldwide. According to Action for Global Health (2011), Italy has 215,000 doctors or 37 doctors per 10,000 people. Ironically, having so many doctors has created a human resource health crisis. Italy is facing a growing shortage of nurses. The high rate of doctors outstrips the available supply of nurses. “There are different estimates of the size of the national shortage but all estimates place it above 50,000 nurses” (Action for Global Health, 2012, p. 30). There were 364,663 nurses or approximately 60 nurses for every 10,000 people in 2009 (Action for Global Health, 2011). Budget constraints, high retirement rates, and the trend toward specialization over primary care are some of the factors that have contributed to the nursing shortage. The nursing profession is subject to the bias toward professions dominated by women in terms of being undervalued and underpaid. Italy has recruited nurses from foreign countries to manage the shortage. However, this strategy has created a resource crisis for other countries. Most of the foreign nurses come from countries such as India and Peru where their services are “desperately” (Action for Global Health, 2011, p. 30) needed, particularly in healthcare coverage for maternal and child immunization (Action for Global Health, 2011).

In 2005, the average monthly salary for doctors was $3,294 and the average monthly salary for nurses was $1,304 to 1,359 (worldsalaries.org). Medical education is regulated by the Ministry of Health. Becoming a physician in Italy requires six years of medical school, a minimum of six months working in a hospital ward, and passing a state examination. Qualifying as a specialist involves successful completion of an exam for admittance to the specialist school, and four to six more years of training, depending on the choice of specialization. Nursing education includes completing a three year university degree and a state examination.

9.4 FINANCING

Italy’s health care is financed through national and regional taxation, i.e., payroll and value added taxes. The NHS provides universal coverage throughout the Italian state as a single payer (Maio & Manzoli, 2002). Physicians are paid on a capitation basis, i.e., a fixed payment at regular intervals for enrolled patients, and hospitals are paid through Diagnosis Related Groups (DRGs).

Under the NHS structure, the 20 regions are responsible for ensuring the equitable delivery of the essential levels of care (the basic benefits package). “The Ministry of Health funds these regions according to a formula based on weighted capitation and past spending. Then the regions allocate these funds to the Local Health Authorities (LHA)” (Healthcare Economist, 2008).

Italy’s attempts to distribute financial resources equitably are attenuated by a number of long standing issues:

• Decentralization: In theory, the state and the regions share the responsibility for enacting the essential levels of care; in practice, however, the regions have full administrative control of funding and regulating health care

• Regional Differences: Tax revenues favor regions with a stronger industrial economy resulting in huge regional differences in the organization and quality of healthcare services

The Benefits Package: Essential Levels of Care

Although voluntary health insurance is available, NHS is the dominant source of health care. Typically, middle to high income groups purchase private insurance. The core package of benefits (the essential levels of care) is described in a catalogue or “health benefit basket” that provides positive and negative lists of healthcare coverage including lists for pharmaceuticals. The positive lists describe the core services NHS is required to provide uniformly to all regions; the negative list identifies services that are excluded based on a variety of criteria including proven clinical ineffectiveness. Regions have the discretion to provide payment for services not covered by the core package but they must use their own funding resources.

Important general observations of the package include the following:

• Inpatient and primary care are free at the point of use. Patients pay co-payments, i.e., out-of-pocket payments for a fraction of the actual cost of care, for tests, diagnostic procedures, and prescription drugs. Co-payments can run as high as 30%. The elderly, pregnant women, and children (about 40% of the population) are exempt from cost sharing (Healthcare Economist, 2008).

• Dental care is not covered by the basic package except for children 0–16, vulnerable populations (people with rare diseases, people with HIV and people in need of urgent or emergency care). “Public coverage of dental services has always been a debated issue in the Italian NHS. Public coverage excludes almost all types of dental services from the nationally defined benefit package” (Torbica & Fattore, 2005, p. 550).

• Hospital coverage is not clearly defined in the package; however, Italian hospitals are paid on nationally predetermined rates based on Diagnostic Related Group classifications (DRGs). DRGs are criticized as roadblocks to innovative practice: “Fixed and outdated tariffs may discourage the adoption of new expensive technologies and may force hospitals to look for alternative sources of funding, often resulting in wide disparities of their availability to citizens” (Torbica & Fattore, 2005, p. 548).

Examples of health services not considered appropriate for coverage include the following:

• Plastic surgery not following accidents, diseases, or genetic malformations

• Ritual circumcision

• Non-conventional medicine (e.g., acupuncture, phyto-therapy, homeopathy, chiropractic)

• Medical certifications, except for scholars

• Non-obligatory vaccinations for traveling purposes

• Some outpatient and physiotherapy and rehabilitation services (e.g., assisted exercises in water; short-wave diathermy, ultra-sound therapy)

Certain Ambulatory and Diagnostic Services are included in the entitlement on a case by case basis:

• Bone density testing (available where there is proven clinical effectiveness)

• Refractory laser surgery

• Orthodontic service

Hospital procedures that should be recommended for substitute treatments and/or other levels of care

• Carpal tunnel release

• Cataract surgery

• Hypertension care

Source: Torbica & Fattore (2005); Fattore, (2004)

Italy’s total health spending accounted for 8 to 10% of GDP between 2007 and 2010, slightly above the average of 9.0% in OCED countries (WHO, 2012; World Bank, 2012; OCED Health Data, 2011).

9.5 INTERVENTIONAL

General Practitioners (GPs) provide most of the primary care in the Italian system and also serve as gatekeepers in charge of referrals to a hospital or specialist. GPs write prescriptions for diagnostic interventions or drugs (Torbica & Fattore, 2005). “Once the general practitioner has authorized the visit or the procedure, the patient is free to choose any provider among those credited by the NHS anywhere in Italy” (Torbica & Fattore, 2005, p.550). In case of an urgent need for care or an emergency, a person can go directly to a Guardia Medica station where on-call physicians are available to provide medical care; ambulance service is free (Maio & Manzoli, 2002).

Despite an apparently generous system, Italian citizens typically indicate low satisfaction with the efficiency and quality of their health care (Maiod & Manzol, (2002); Blendon, Kim, & Benson, 2001). Following the GP’s referral, patients move from one long wait list to the next for each level of care they may require. Available data suggests that the average wait time for a mammogram is 70 days and for an endoscopy is 74 days (Healthcare Economist, 2005).

Long-Term Care (LTC)

Italy’s long-term care system provides services to the elderly, the disabled, persons with drug and/or alcohol dependency, and individuals who require psychiatric services. Long-term care is delivered by public and private providers of health and personal social care. “Health services provided by the National Health Service are free-of-charge, whereas social care is means-tested, and users can pay up to the full cost of it” (Tediosi & Gabriele, 2010, p. 1).

Among OECD countries, Italy has one of the lowest rates of long term bed availability. In their study of patterns of long term care in several European countries, Damiani et al. observe the following: “The provision of long term care beds in institutions (other than hospitals) ranges from less than 2% of the population aged 65 and over in Italy to 8% in Sweden, while the percentage of the elderly who are cared for either in institutions or at home ranges from less than 5% in Italy to more than 20% in Norway” (2011, p. 2).

Italy provides long-term care for the elderly in three modalities: community home care, residential care, and cash allowances (Tediosi & Gabriele, 2010). Community home care is for people who do not have serious debilitating illnesses. Home-based care is financed by the government and includes services such as primary care, rehabilitation, medical equipment, and drug deliveries (Tediosi & Gabriele, 2010) Access to home care requires an application to the local health authorities (LHAs) who then determine the person’s eligibility for this level of service (Tediosi & Gabriele, 2010).

Italy provides three different types of residential services: nursing homes for dependent patients; residents aimed at a specific time period for release and designed for people who need assistance with recovering as much psych-motor and mental capacity as possible; and assisted living situations for people who are mainly self-sufficient (Tediosid & Gabriele, 2010). “The number of elderly persons in institutional care is still relatively low by international standards, being 19.8 per 1,000 inhabitants aged 65 or older (Tediosi & Gabriele, 2010, p. 1).

Gaining access to residential care requires a few more steps. The patient must have a doctor’s referral to request institutional care; the doctor completes the application and then a residential assessment team evaluates whether the person should be admitted.

Cash benefits are paid to disabled people (irrespective of age or income) and are provided by the National Institute of Social Security (INPS). A person’s eligibility for cash benefits is first assessed by the LHA and then passed on to an INPS commission for a final decision. “Persons eligible for this cash benefit must be assessed as 100% disabled and dependent, i.e., unable to walk without the permanent help of a companion or unable to carry out the activities of daily living and in need of continuous assistance; and not in a residential institution whereby the costs are charged to the public administration. This cash benefit is provided every month; beneficiaries are free to use it to purchase LTC services or not, and in 2009, the monthly benefit was set at $472” (Tediosi & Gabriele, 2010, p. 4).

The quality and effectiveness of Italy’s long-term care system is called into question by the following issues:

• The lack of an integrated network of delivery between health and social care service.

• Wide regional differences in public expenditures for long-term care services

• Inadequate funding of personal social services

• The lack of a national policy to provide monetary support to informal caregivers (e.g., family members). Despite universal coverage, families not only share a large part of the financial care for their elderly relatives; they often become the principal caregivers.

9.6 PREVENTIVE

Under Italy’s healthcare system, each LHA has a division of health care responsible for prevention and health promotion. Within the past decade, Italy has initiated several preventive measures that emphasize an integrated approach to healthcare delivery. The National Health Plans 2006–2008 has targeted syndromic surveillance systems as an important innovation for improving public health. Recognizing the serious role the General Practitioner (GP) plays in prevention, Italy has planned training programs on cardiovascular prevention for GPs in monitoring cardiovascular risk and risk factor trends in patients, including patient records of prescribed therapies and life style recommendations (Donfrancesco et al., 2008).

The European heat wave of 2003 took at least 35,000 lives; nearly 4,200 lives were lost in Italy (Bhattacharya, 2005). In 2004, the Italian Department for Civil Protection and the Ministry of Health implemented a national program for the prevention of heat-health effects during summer. Within five years of operation, the program reached national coverage of 93% of the population aged 65 and over living in urban areas. The Italian program is recognized as “ an important example of a collaborative network with a central coordination based on city-specific Heat Health Watch Warning Systems (HHWWS), mortality surveillance systems, and a wide range of local prevention activities” (Michelozzi et al., 2010, p. 2270).

In Italy, around 270,000 road traffic accidents occur annually, causing almost 330,000 injuries and 7,000 deaths (LaTorre, Van Beeck, Quaranta, Mannocci & Ricciardl, 2007). In regard to domestic accidents, Sanson et al. assert that, “despite the dimension of the problem, rare structured initiatives have been realized. A turning point was represented by the National Prevention Plan and the National Health Plan 2006–2008 which promoted a national working group and stimulated regional studies and initiatives on the prevention of domestic accidents.” (2010, p.1).

Italy has also initiated several quality information systems to make information more useful to patients (e.g., avoiding jargon).

9.7 RESOURCES

A number of cultural beliefs concerning health, such as the evil eye, are practiced by older Italians. Traditional treatment is supplemented with home remedies such as the use of healers, potion makers, and the concept of healing hands designed to relieve soreness and repair broken bones. New Age approaches to health are steadily being adopted by Italian citizens and gaining approval from once reluctant physicians. Complementary/alternative medicine (CAM) is not financed under the healthcare package except where treatment may benefit pathologies such as rheumatism or osteoarthritis (Torbica & Fattore, 2005). Available survey data suggest women are the main consumers of CAM and that people aged 35–44 are the most frequent group to utilize alternative approaches to health care. In their look at the use of CAM, among women experiencing menopausal symptoms, Cardini and colleagues found that patients were more likely than their physician, to ask for alternative treatments, and that the three most popular practitioners consulted were herbalists, nutritionists, and homeopaths (Cardini, Grazia, Lombardo, & van der Sluijs, 2010).

9.8 MAJOR HEALTH ISSUES

Table 9-2 lists the top 10 health issues in Italy by number and percent, and years of life lost. Cardiovascular disease is the leading cause of death in Italy, followed by cancer and respiratory diseases. Considerable attention is being given to addressing, in particular, obesity and smoking, both of which are precursors to the development of these leading causes of death

Table 9-2 Top 10 causes of death (all ages) in Italy, 2002, with the number and percent of years of life lost by disease.

Data From: Death and DALY estimates by cause, 2002. http://www.who.int/entity/healthinfo/statistics/bodgbddeathdalyestimates.xls

9.9 DISPARITIES

Italy’s efforts to decrease disparities are continuously challenged by regional variations in healthcare delivery. “Out of 13 European countries, Italy’s regional income disparities are the most pronounced resulting in high regional health disparities” (Franzini & Giannoni, 2010, p. 1). Marked socio economic differences are evident between the developed industrial north, and the less developed, welfare-dependent agricultural south with high unemployment (CIA, 2011). In what the literature frequently refers to as the north-south divide, residents in the southern regions are more likely than their northern counterparts, to report poor self-assessed health, and less satisfaction with health services. The southern region is associated with higher rates of chronic disease, higher cancer rates, and higher mortality rates (Franzini & Giannoni, 2010). Due to inadequate medical services in the southern areas, patients migrate to the northern areas for treatment out of a belief that the services are better, and for the diagnostic services they may require.

SUMMARY

With France in the lead, Italy is favorably regarded as the second best healthcare system in the world, particularly with respect to health status, fairness in financial contribution, and responsiveness to people’s expectations of the health system (Maio & Manzoli, 2002). However, as several experts and researchers observe, this ranking is controversial because it does not consider public perceptions of the system. Since its inception in 1978, the Italian National Health Service has demonstrated considerable success in protecting public health through effective therapeutic measures and prevention campaigns resulting in reduced rates of cervical cancer, infectious diseases, and increased life expectancy. However, Italy’s high standing and accomplishments are overshadowed by sharp regional differences in healthcare delivery. The marked regional differences in socio-economic status create the north-south divide that continues to challenge Italy’s efforts to provide a uniform, equitable system of health care.

Lovett-Scott, M., & Prather, F. (2018). Global health systems: Comparing strategies for delivering health services .

· Chapter 9: The Healthcare System in Italy

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8.1 INTRODUCTION

France, a leader among European countries, is a developed (industrialized) world power that has a good healthcare system and a strong economy. This Western European land area of 545,630 square km is nestled among six countries: The United Kingdom, Germany, Belgium, Switzerland, Italy, and Spain, and three major waterways: the Bay of Biscay, the English Channel, and the Mediterranean Sea.

According to the CIA World Factbook (CIA, 2009), in 2001 France’s population was approximately 59,551,227, of whom 65.19% were between the ages of 15 and 64. Slightly more than 16% of the population was 65 years and older. The majority of France’s residents are natives of France. However, France is home to some immigrants and has a particularly strong African and Southeast Asian presence. The proportion of France’s under 15-year-old age groups is 18% (UNO, 2004), and the over 60 population is 20% (WHO, 2004). The predominant language spoken in France is French. The largest ethnic groups are Celtic, Latin, and Teutonic. Other ethnic groups are Slavic, Northern African, and South East Asian. The largest religious group in France is Roman Catholic (WHO, n.d.). Overall life expectancy in France is 78.9 years, 83.01 years for women, and 75.01 for men. Total fertility rate is 1.75 children born per woman. The infant and neonatal mortality rate was estimated to be 4.46 deaths/1,000 live births and this number has steadily decreased over the years. France’s literacy rate is 99% for men and women. Women are well educated and are very competitive.

Like most other industrialized countries, French residents enjoy a universal healthcare system that is largely financed through national healthcare insurance and is ranked among the best healthcare systems in the world (WHO, 2000).

8.2 HISTORICAL

France, priding itself on its promise to take good care of its entire population, has had a form of National Health Care since 1945. The country has always had a threefold goal; to provide a single health insurer, make it compulsory for all employers and workers to pay premiums based on their salaries, and allow patients to choose their own doctors. However, doctors are permitted to charge additional fees and prescribe therapies, diagnostic procedures, and medications as they see fit, without interference from the national health insurance. Unlike some healthcare systems that offer universal health there are no long waiting periods to schedule elective surgery or see specialists in France.

Legislation in 1999 further refined the national health insurance plan mandating that anyone with a regular residence permit was entitled to health benefits without strings attached. This legislation also clarified that illegal residents would be managed by giving them full coverage if they could prove they lived in a French territory for more than three months and had no financial means to pay for health care (Gauthier-Villars). In a 2000 WHO ranking of the best healthcare systems worldwide, France was ranked number one. It has, over the past 30 years, been forced to reduce its healthcare coverage and incrementally increase its healthcare taxes. However, consumers still give France high marks for its healthcare delivery and quality.

8.3 STRUCTURE

Healthcare administration and oversight is provided by the Minister of Health and Solidarity. This cabinet position oversees the healthcare public services and the health insurance part of Social Security

The government pays for medical school for those seeking to pursue medicine as a career. Once licensed, most physicians work in private practice but their fees-for-services are paid by publically-funded insurance companies. General practitioners, commonly referred to as docteurs, are responsible for all aspects of care, including acute and chronic. They are key in providing treatment of diseases not requiring a specialist and they provide preventive services. General practitioners can be summoned by the samu, the emergency medical services to assist with emergency care.

Physicians make a modest net average annual salary of approximately €40,000 (Tanner, 2008), the equivalent of $51,243. This is approximately one-third that of physicians in the United States. Because French physicians charge relatively low fees for services, many earn more by increasing their patient load, or by prescribing more diagnostic tests and procedures—a technique, also popular in the United States, that inflates healthcare costs (Capell, July 2007, p. 12). Once physicians have practiced in a hospital for at least four years it is permissible for them to charge extra fees for consultations (Capell, July 2007). This is another way in which the salary can be increased. Approximately 90% of France’s general practitioners have an agreement with Assurance Maladie, the country’s largest buyer of medical services that prevents them from charging more than €22 ($32.00) for a consultation, and an additional €3.50 if they make a house call (Gauthier-Villars, 2009). Gauthier-Villars, quotes nurse practitioner Lanfranchi, as saying, “If you are in medical care for the money, you’d better change jobs” (p. 4).

Nurses in France receive professional training for three years to gain the basic entry level into practice. Advanced practice nurses are not included in the French model for nursing practice. In 2004, there were approximately 6.7 practicing nurses per 1,000 people in the population as compared to 3.37 physicians (OECD, 2008).

8.4 FINANCING

France, like the United States, relies on both private insurance and government insurance which is generally obtained through the person’s employer. Everyone pays compulsory health insurance to non-profit agencies that participate in annual fee-setting negotiations with the state. There are three main funds that, when combined, provide coverage for approximately 96% of the population. The compulsory premium is automatically deducted from all employees’ pay. The 2001 Social Security Funding Act sets the rates for health insurance covering the statutory healthcare plan at 5.25% on earned income, capital, and winnings from gambling, and at 3.95% on pension benefits and other allowances (WHO, 2000).

France spends approximately 11 percent of its GDP on health care. Health care is funded through taxes proportionate to the person’s income which funds Assurance Maladie, a state health insurer that has operated in the red since 1989. Budgetary shortfalls are predicted to exceed €9 bill ($13 billion) in 2011 (Gauthier-Villars, p.2). When a person visits a doctor in France, 70% of the bill is covered by the national insurance program. The remaining 30% is covered by supplemental private insurance, which literally everyone has because it is affordable, and in almost all cases is paid for by employers. The entire cost of care is paid by the national insurance program for persons with long-term chronic illnesses, diabetes, cancer, and heart diseases. Also 100% of major surgeries are covered.

Approximately 65% of hospital beds in France are publically operated, 15% are private non-profit, and approximately 20% are privately run for-profit hospitals (WHO, 2000). There are also private and public funded clinics, doctor offices, and special centers called Protection Maternelle et Infantile (PMI) discussed under the Preventive section.

8.5 INTERVENT

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