The Italian National Health System: Structure, funding and evolution

The introduction of a casemix system in Italy is quite symbiotic with the evolution of its National Health Care System (SSN – Servizio Sanitario Nazionale), first created in 1978 and then reshaped in the 1990s through a process of institutional and financial decentralization (from state to regions), combined with a delegation of managerial autonomy to the lower levels of health care provision and payment. Previously, until 1992, the system was basically administered by local municipalities following an ideal of democratic participation and local control, but often with a bureaucratic and inefficient use of resources (Donatini et al. 2001).

In 1978, the SSN replaced a system of health insurance funds in order to provide the entire population with uniform and comprehensive care, on the basis of both payroll and general taxation and according to the constitutional principle of ‘solidarity and freedom of choice for the patient’ (mainly concerning the provider and settings of care). In terms of figures, 2005 Italian health care public expenditures were €95 billion in current prices, equal to 6.4 percent of GDP, but growing to 8.4 percent with private out-of-pocket spending (OECD 2006), serving a population of 57.3 million (meaning a public per-capita expenditure of €1,828). In 2004, hospitals absorbed, on average, 48 percent of public expenditures, 12 percent of outpatient services, and 6 percent of primary care.