Healthcare and social security are the pillars of welfare. The aim of the national healthcare systems is to promote and improve the citizens’ health through empowerment, prevention, diagnosis, treatment and rehabilitation initiatives. Health indicators measure a central item in the state budget and above all a primary element of the social assistance. Over more than a decade, in Italy and in the European Union, the healthcare system has been subject to reforms aimed at rationalising and containing expenditure.
In 2019, in Italy among the adult population (18 years old and over) the share of smokers was equal to 18.4%, the share of alcohol consumers at risk was equal to 15.4% and finally the share of obese persons was equal to 10.9%. The "Gaining Health" program of the European Region of the World Health Organization supports economic, health and communication interventions aimed at opposing the spread of the main risk factors such as smoking, alcohol, unhealthy food choices and a sedentary lifestyle (the latter is closely related to obesity).
In the European area, public financing scheme of health services is the prevailing choice. In 2019, the direct contribution of Italian households to overall health expenditure (public and private) amounted to 25.9%, only 0.3 percentage points higher than in 2004. Households’ expenditure on health accounted for 2% of the GDP.
In 2018, Italy’s public current expenditure on health amounted to approximately 113 billion euros, equal to 6.5% of GDP and 1,875 euros per inhabitant.
The hospital supply continues to decline over time: the trend towards an organization of hospital care increasingly integrated with ambulatory care has resulted in a decrease in the number of hospitals (from 1,378 in 2002 to 1,048 in 2018) and in the supply of hospital beds (from 4.4 per thousand inhabitants to 3.1 in the same period). These trends derive from regulatory interventions aimed at reducing and rationalizing health expenditure, promoting the de-hospitalization of less complex patients that are treated by the territorial services.
In 2019, 1,810 inpatient hospitalizations per one hundred thousand inhabitants for diseases concerning the circulatory system and 1,102 concerning neoplasms were recorded. In both cases, a decrease compared to the previous year was registered. Gender gap was high for the diseases concerning the circulatory system (2,186 for men, 1,452 for women) but it was low for those concerning neoplasms (1,105 for men, 1,099 for women). The progressive reduction in hospitalizations for those diseases was mainly determined by the outpatient treatment of patients in ambulatory services, rather than by changes in the epidemiological situation of the population.
In 2018, the (standardized) mortality rate for all causes amounted to 82.9 deaths per 10,000 inhabitants, registering a decrease compared to 2017 (86.7 per 10,000 inhabitants), when the mortality level had reached a peak. The mortality rate of diseases of the circulatory system, responsible for the majority of deaths, decreased by about 25% over the last ten years for both men and women (24.7 deaths per 10.000 inhabitants in 2018). The decrease in mortality for neoplasms at a national level continued (24.7 per 10 thousand inhabitants), thanks to the success of primary prevention measures as well as diagnostic and therapeutic progresses. For both causes, men show higher mortality rates than women, but for neoplasms, the gender gap has been decreasing over time. The infant mortality rate, an important indicator of the level of development and well-being of a country, was just below three deaths per thousand live births; this value has been quite stable since 2014.
In 2019, the phenomena of high-risk alcohol consumption and obesity highlighted regional disparities: in the Centre and North, the share of alcohol consumers at risk was higher (16.7%), while in the South and in the Northeast, that of obese persons was higher (12.1% and 11.4% respectively). With regard to smokers, the highest share was recorded in the Centre, in particular in Lazio (22.7%) and Umbria (21.7%).
In 2018, the expenditure on health per inhabitant in the Northeast (1,915 euros) and North-west (1,930 euros) were similar and above the national average (1,875 euros), the Centre showed a value just below the national average (1,862 euros), while in the South and Islands (1,816 euros) the per capita expenditure was lower than the national average.
Total health expenditure (public and private) in 2018 amounted to 8.6% of GDP, financed by out of pocket households’ expenditure for 1.2 percentage points. Households’ contribution to the total health expenditure decreased between 2004 and 2014, but started to increase from 2015. Instead, in the same period, the overall health expenditure to GDP ratio increased by 0.5 percentage points. The increase was entirely financed through a growth in public spending (although the contribution of private spending to the overall expenditure has grown in recent years).
The incidence of the households’ health expenditure as a percentage of the regional GDP was higher in the South and Islands (2.5%) and in the Northeast (2.2%). Instead, in Calabria, Friuli-Venezia Giulia, Valle d’Aosta/Vallée d’Aoste, Puglia, Basilicata, Molise and Sardegna the share was higher (over 2.5% of the regional GDP). Considering the distribution of health expenditure between the two components, public and private, the contribution of families to overall health expenditure is lower in the Southern Italy (20.1%) than in the Centre-North, where it stood at 27.2%, with a peak of 29.3%, in the Northeast.
The higher contribution of households to the health expenditure was registered in Valle d’Aosta/Vallée d’Aoste (31.7%), Friuli-Venezia Giulia (30.4%) and Emilia-Romagna (30%). These values were above the national average and the Northeast one. On the other hand, the lowest incidences were registered in South and Islands, and in particular in Campania and Sicilia.
The number of hospital beds further decreased in all the Italian regions. In Lazio, Tuscany and Calabria, the highest reduction has been recorded since 2002. In 2018, Calabria (2.5 beds per thousand inhabitants) and Campania (2.6) showed the lowest rate while Emilia Romagna (3.7) and Valle d’Aosta/Vallée d’Aoste (3.6) the highest one.
In 2019, all the southern regions, with the exception of Molise, showed an attraction index lower than one, i.e. a passive mobility greater than the active one. In Calabria, about one in five hospitalization took place outside the region of residence. Lombardy and Emilia Romagna, on the other hand, showed an attraction index equal to 2.7 and a percentage of hospital immigration equal to 12.2% and 15.5% respectively.
In 2017, controlling for the differences due to the composition by age of the population, the mortality rate for all causes highlighted a disadvantage in the South and Islands. Infant mortality was also higher in the South and Islands and the difference with the Central and Northern areas has not decreased over the last ten years. Although mortality for neoplasms was on average lower in the South and Islands, Campania showed the highest rate for males.
In 2019, Italy, showing a percentage of smokers equal to 18.6% of the population (aged 15 or over), ranked in a central position in the ranking of EU countries. Greece (35.0%), Hungary (25.8%), France (25.4%) and Austria (24.3%) ranked at the top. Smoking was less common in Sweden (10.1%), Finland (13%) and Ireland (14%).
In addition, in 2019, Italy showed a percentage of obese persons equal to 10.9% of the population (aged 15 or over); this value placed it among the countries with the lowest values, along with Sweden (14.1%) and the Netherlands (14.4%). The United Kingdom and Finland (21%), Ceca Republic (20.5%) and Hungary (20.0%) showed the highest values.
The Italian public current expenditure on health is far lower than that of other European countries. At purchasing power parity, compared to approximately $3,485 per inhabitant spent in Italy in 2018, United Kingdom, Ireland and Finland exceeded $4,000; Austria, Belgium and France showed a value above $5,000, while Germany ($6,224 per inhabitant) ranked first.
The comparison among European countries showed that in 2019, in Italy, the share of private health expenditure on overall health expenditure (public and private) was 25.9%, near to the shares observed in Estonia and Ireland. The country showing the higher private spending was Greece (40.7%), followed by Portugal (38.8%) and Hungary (30.6%). All the others European countries recorded a share of private expenditure below 30%; in particular the lowest shares were recorded in Germany (15%), Sweden (14.8%) and Luxembourg (14.1%).
With regard to the supply of hospital beds, Italy ranked 23th with a value strongly below the European average (3.1 beds per thousand inhabitants in Italy, compared to the EU average value of 5.0). In the European context, Italy, with 1,102 inpatient hospitalizations per 100,000 inhabitants for neoplasms and 1,810 inpatient hospitalizations for diseases of the circulatory system, was placed in the first half of the ranking with hospitalization rates similar to France and Belgium.
In 2017, the death rates for neoplasms and for diseases of the circulatory system were both below the European average. In 2018, Italy was still one of the countries with the lowest infant mortality rate (2.8 per thousand live births, while the EU average is 3.5 per thousand), the value registered in Italy is similar to that recorded in Ireland, Spain and Austria.