Italy: Health System Review.

This analysis of the Italian health system reviews recent developments in organization and governance, health financing, health care provision, health reforms and health system performance. Italy has a regionalized National Health Service (SSN) that provides universal coverage largely free of charge at the point of delivery, though certain services and goods require a co-payment. Life expectancy in Italy is historically among the highest in the EU. However, regional differences in health indicators are marked, as well as in per capita spending, distribution of health professionals and in the quality of health services. Overall, Italy's health spending per capita is lower than the EU average and is among the lowest in western European countries. Private spending has increased in recent years, although this trend was halted in 2020 during the coronavirus disease 2019 (COVID-19) pandemic. A key focus of health policies in recent decades was to promote a shift away from unnecessary inpatient care, with a considerable reduction of acute hospital beds and stagnating overall growth in health personnel. However, this was not counterbalanced by a sufficient strengthening of community services in order to cope with the ageing population's needs and related chronic conditions burden. This had important repercussions during the COVID-19 emergency, as the health system felt the impact of previous reductions in hospital beds and capacity and underinvestment in community-based care. Reorganizing hospital and community care will require a strong alignment between central and regional authorities. The COVID-19 crisis also highlighted several issues pre-dating the pandemic that need to be addressed to improve the sustainability and resilience of the SSN. The main outstanding challenges for the health system are linked to addressing historic underinvestment in the health workforce, modernizing outdated infrastructure and equipment, and enhancing information infrastructure. Italy's National Recovery and Resilience Plan, underwritten by the Next Generation EU budget to assist with economic recovery from the COVID-19 pandemic, contains specific health sector priorities, such as strengthening the country's primary and community care, boosting capital investment and funding the digitalization of the health care system.

Early health system responses to the COVID-19 pandemic in Mediterranean countries: A tale of successes and challenges.

This paper conducts a comparative review of the (curative) health systems' response taken by Cyprus, Greece, Israel, Italy, Malta, Portugal, and Spain during the first six months of the COVID-19 pandemic. Prior to the COVID-19 pandemic, these Mediterranean countries shared similarities in terms of health system resources, which were low compared to the EU/OECD average. We distill key policy insights regarding the governance tools adopted to manage the pandemic, the means to secure sufficient physical infrastructure and workforce capacity and some financing and coverage aspects. We performed a qualitative analysis of the evidence reported to the 'Health System Response Monitor' platform of the European Observatory by country experts. We found that governance in the early stages of the pandemic was undertaken centrally in all the Mediterranean countries, even in Italy and Spain where regional authorities usually have autonomy over health matters. Stretched public resources prompted countries to deploy "flexible" intensive care unit capacity and health workforce resources as agile solutions. The private sector was also utilized to expand resources and health workforce capacity, through special public-private partnerships. Countries ensured universal coverage for COVID-19-related services, even for groups not usually entitled to free publicly financed health care, such as undocumented migrants. We conclude that flexibility, speed and adaptive management in health policy responses were key to responding to immediate needs during the COVID-19 pandemic. Financial barriers to accessing care as well as potentially higher mortality rates were avoided in most of the countries during the first wave. Yet it is still early to assess to what extent countries were able to maintain essential services without undermining equitable access to high quality care.

"Top-Three" health reforms in 31 high-income countries in 2018 and 2019: an expert informed overview.

BACKGROUND: High-income countries continuously reform their healthcare systems. Often, similar reforms are introduced concomitantly across countries. Although national policymakers would benefit from considering reform experiences abroad, exchange is limited. This paper provides an overview of health reform trends in 31 high-income countries in 2018 and 2019, i.e., before Covid-19. METHODS: Information was collected from national experts from the Health Systems and Policy Monitor network. Experts were asked to report on the three "top" national health reforms 2018 and 2019. In 2019, they provided an update of 2018 reforms. Reforms were assigned to one of 11 clusters and identified as one of seven different reform types. RESULTS: 81 reforms were reported in 28 countries in 2018. 44/81 went to four clusters: 'insurance coverage & resource generation', 'governance', 'healthcare purchasing & payment', and 'organisation of hospital care'. In 2019, 86 reforms in 30 countries were reported. 48/86 fell under 'organisation of primary & ambulatory care', 'governance', 'care coordination & specialised care', and 'organisation of hospital care'. Most 2018 reforms were reported ongoing in 2019; 27 implemented; seven abandoned. Health agency-led reforms were implemented most frequently, followed by central government-legislated reforms. CONCLUSIONS: Policymakers can leverage international experience of distinct reform approaches addressing similar challenges and similar approaches to address distinct problems. Such knowledge may help inspire or support future successful health reform processes.

Germany: Health System Review.

This analysis of the German health system reviews recent developments in organization and governance, health financing, health care provision, health reforms and health system performance. Germany's health care system is often regarded as one of the best health care systems in the world, offering its population universal health insurance coverage and a comprehensive benefits basket with comparably low cost-sharing requirements. It provides good access to care with free choice of provider and short waiting times, which is partly due to good infrastructure with a dense network of ambulatory care physicians and hospitals, and a quantitatively high level of service provision. With the largest economy in the EU it is not surprising that Germany spends more than other countries on health, with most financing coming from public funds. The country had the highest per capita spending in the EU in 2018. In relation to overall health expenditure and available resources, a very high number of services is provided across sectors, particularly in hospital and ambulatory care. This can be seen as achieving a considerable level of technical efficiency. Given the high volumes, however, there are questions about the oversupply of services, as well as some comparatively moderate health and quality outcomes; from this perspective, there are signs that there is room for improvement in how the system allocates resources. Additional challenges in the German health system may be identified in: (1) the strong separation of ambulatory and inpatient care in terms of organization and payment, which can hinder the coordination and continuity of patient treatment; (2) the coexistence of statutory health insurance (SHI) and substitutive private health insurance (PHI), which weakens the principle of solidarity; and (3) a complex stewardship framework which promotes incrementalism and makes it more difficult to implement reforms.

Health decentralization at a dead-end: towards new recovery plans for Italian hospitals.

The recent introduction by the central government of recovery plans (RPs) for Italian hospitals provides useful insights into the recentralization tendencies that are being experienced within the country's decentralized, regional health system. The measure also contributes evidence to the debate on whether there is a long-term structural shift in national health strategy towards more centralized stewardship. The hospital RPs aim to improve the clinical, financial and managerial performance of public-hospitals, teaching-hospitals and research-hospitals through monitoring trends in individual hospitals' expenditure and tackling improvements in clinical care. As such they represent the central governments recognition of the weaknesses of the decentralization process in the health sector. The opponents of the reform argue that financial stability will be restored mainly through across-the-board reductions in hospital expenditure, personnel layoffs and closing of wards, with considerable negative effects on the most vulnerable groups of patients. While hospital RPs are comprehensive and complex, unresolved issues remain as to whether hospitals have the necessary managerial skills for the development of effective and achievable plans. Without also devising an overall plan to tackle the long-standing managerial weaknesses of public hospitals, the objectives of the hospital RPs will be undermined and the decentralization process in the health system will gradually reach a dead-end.

Greece: Health System Review.

This analysis of the Greek health system reviews developments in its organization and governance, health financing, health care provision, health reforms and health system performance. The economic crisis has had a major impact on Greek society and the health system. Health status indicators such as life expectancy at birth and at age sixtyfive are above the average in the European Union but health inequalities and particular risk factors such as high smoking rates and child obesity persist. The highly centralized health system is a mixed model incorporating both tax-based financing and social health insurance. Historically, a number of enduring structural and operational inadequacies within the health system required addressing, but reform attempts often failed outright or stagnated at the implementation phase. The countrys Economic Adjustment Programme has acted as a catalyst to tackle a large number of wide-ranging reforms in the health sector, aiming not only to reduce public sector spending but also to rectify inequities and inefficiencies. Since 2010, these reforms have included the establishment of a single purchaser for the National Health System, standardizing the benefits package, re-establishing universal coverage and access to health care, significantly reducing pharmaceutical expenditure through demand and supply-side measures, and important changes to procurement and hospital payment systems; all these measures have been undertaken in a context of severe fiscal constraints. A major overhaul of the primary care system is the priority in the period 2018-2021. Several other challenges remain, such as ensuring adequate funding for the health system (and reducing the high levels of out-of-pocket spending on health); maintaining universal health coverage and access to needed health services; and strengthening health system planning, coordination and governance. While the preponderance of reforms implemented so far have focused on reducing costs, there is a need to develop this focus into longer-term strategic reforms that enhance efficiency while guaranteeing the delivery of health services and improving the overall quality of care.

Slovenia: Health System Review.

This analysis of the Slovene health system reviews recent developments in organization and governance, health financing, health care provision, health reforms and health system performance. The health of the population has improved over the last few decades. While life expectancy for both men and women is similar to EU averages, morbidity and mortality data show persistent disparities between regions, and mortality from external causes is particularly high. Satisfaction with health care delivery is high, but recently waiting times for some outpatient specialist services have increased. Greater focus on preventive measures is also needed as well as better care coordination, particularly for those with chronic conditions. Despite having relatively high levels of co-payments for many services covered by the universal compulsory health insurance system, these expenses are counterbalanced by voluntary health insurance, which covers 95% of the population liable for co-payments. However, Slovenia is somewhat unique among social health insurance countries in that it relies almost exclusively on payroll contributions to fund its compulsory health insurance system. This makes health sector revenues very susceptible to economic and labour market fluctuations. A future challenge will be to diversify the resource base for health system funding and thus bolster sustainability in the longer term, while preserving service delivery and quality of care. Given changing demographics and morbidity patterns, further challenges include restructuring the funding and provision of long-term care and enhancing health system efficiency through reform of purchasing and provider-payment systems.

Iceland: health system review.

This analysis of the Icelandic health system reviews the developments in its organization and governance, health financing, health care provision, health reforms and health system performance. Life expectancy at birth is high and Icelandic men and women enjoy longer life in good health than the average European. However, Icelanders are putting on weight, more than half of adult Icelanders were overweight or obese in 2004, and total consumption of alcohol has increased considerably since 1970. The health care system is a small, state centred, publicly funded system with universal coverage, and an integrated purchaser provider relationship in which the state as payer is also the owner of most organizations providing health care services. The country's centre of clinical excellence is the University Hospital, Landspitali, in the capital Reykjavik, which alone accounts for 70 percent of the total national budget for general hospital services. However, since 1990, the health system has become increasingly characterized by a mixed economy of care and service provision, in which the number and scope of private non profit and private for profit providers has increased. While Iceland's health outcomes are some of the best among OECD countries, the health care system faces challenges involving the financial sustainability of the current system in the context of an ageing population, new public health challenges, such as obesity, and the continued impact of the country's financial collapse in 2008. The most important challenge is to change the pattern of health care utilization to steer it away from the most expensive end of the health services spectrum towards more cost efficient and effective alternatives. To a large degree, this will involve renewed attempts to prioritize primary care as the first port of call for patients, and possibly to introduce a gatekeeping function for GPs in order to moderate the use of specialist services.

Italy: health system review.

Italy is the sixth largest country in Europe and has the second highest average life expectancy, reaching 79.4 years for men and 84.5 years for women in 2011. There are marked regional differences for both men and women in most health indicators, reflecting the economic and social imbalance between the north and south of the country. The main diseases affecting the population are circulatory diseases, malignant tumours and respiratory diseases. Italy's health care system is a regionally based national health service that provides universal coverage largely free of charge at the point of delivery. The main source of financing is national and regional taxes, supplemented by copayments for pharmaceuticals and outpatient care. In 2012, total health expenditure accounted for 9.2 percent of GDP (slightly below the EU average of 9.6 percent). Public sources made up 78.2 percent of total health care spending. While the central government provides a stewardship role, setting the fundamental principles and goals of the health system and determining the core benefit package of health services available to all citizens, the regions are responsible for organizing and delivering primary, secondary and tertiary health care services as well as preventive and health promotion services. Faced with the current economic constraints of having to contain or even reduce health expenditure, the largest challenge facing the health system is to achieve budgetary goals without reducing the provision of health services to patients. This is related to the other key challenge of ensuring equity across regions, where gaps in service provision and health system performance persist. Other issues include ensuring the quality of professionals managing facilities, promoting group practice and other integrated care organizational models in primary care, and ensuring that the concentration of organizational control by regions of health-care providers does not stifle innovation.

Veneto Region, Italy. Health system review.

The Health Systems in Transition (HiT) profiles are country-based reports that provide a detailed description of a health system and of policy initiatives in progress or under development. This HiT is one of the first to be written on a subnational level of government and focuses on the Veneto Region of northern Italy. HiTs examine different approaches to the organization, financing and delivery of health services and the role of the main actors in health systems; describe the institutional framework, process, content and implementation of health and health care policies; and highlight challenges and areas that require more in-depth analysis. The Veneto Region is one of Italy's richest regions and the health of its resident population compares favourably with other regions in Italy. Life expectancy for both men and women, now at 79.1 and 85.2 years, respectively, is slightly higher than the national average, while mortality rates are comparable to national ones. The major causes of death are tumours and cardiovascular diseases. Under Italy's National Health Service, the organization and provision of health care is a regional responsibility and regions must provide a nationally defined (with regional input) basic health benefit package to all of their citizens; extra services may be provided if budgets allow. Health care is mainly financed by earmarked central and regional taxes, with regions receiving their allocated share of resources from the National Health Fund. Historically, health budget deficits have been a major problem in most Italian regions, but since the early 2000s the introduction of efficiency measures and tighter procedures on financial management have contributed to a significant decrease in the Veneto Regions health budget deficit.The health system is governed by the Veneto Region government (Giunta) via the Departments of Health and Social Services, which receive technical support from a single General Management Secretariat. Health care is provided by 21 local health and social care units, 2 hospital enterprises, 2 national hospitals for scientific research and private accredited providers. Major national health reform legislation in the 1990s started the process of regionalization of the health system and the introduction of managerial methods and quasi-market mechanisms into the National Health Service, a process that has been consolidated since the early 2000s under the framework of fiscal federalism. Future challenges for the Veneto Region include the sustainable provision of the basic health benefit package; the adaptation of services to meet changes in demand, particularly those associated with the ageing population and the incidence of chronic diseases; and the ever-present problem of keeping the regional health budget balanced.

Turkey. Health system review.

Turkey has accomplished remarkable improvements in terms of health status in the last three decades, particularly after the implementation of the Health Transformation Program (HTP (Saglikta Donus, um Programi)). Average life expectancy reached 71.8 for men and 76.8 for women in 2010. The infant mortality rate (IMR) decreased to 10.1 per 1000 live births in 2010, down from 117.5 in 1980. Despite these achievements, there are still discrepancies in terms of infant mortality between rural and urban areas and different parts of the country, although these have been diminishing over the years. The higher infant mortality rates in rural areas can be attributed to low socioeconomic conditions, low female education levels and the prevalence of infectious diseases. The main causes of death are diseases of the circulatory system followed by malignant neoplasms. Turkeys health care system has been undergoing a far-reaching reform process (HTP) since 2003 and radical changes have occurred both in the provision and the financing of health care services. Health services are now financed through a social security scheme covering the majority of the population, the General Health Insurance Scheme (GHIS (Genel Saglik Sigortasi)), and services are provided both by public and private sector facilities. The Social Security Institution (SSI (Sosyal Guvenlik Kurumu)), financed through payments by employers and employees and government contributions in cases of budget deficit, has become a monopsonic (single buyer) power on the purchasing side of health care services. On the provision side, the Ministry of Health (Saglik Bakenligi) is the main actor and provides primary, secondary and tertiary care through its facilities across the country. Universities are also major providers of tertiary care. The private sector has increased its range over recent years, particularly after arrangements paved the way for private sector provision of services to the SSI. The most important reforms since 2003 have been improvements in citizens health status, the introduction of the GHIS, the instigation of a purchaser provider split in the health care system, the introduction of a family practitioner scheme nationwide, the introduction of a performance-based payment system in Ministry of Health hospitals, and transferring the ownership of the majority of public hospitals to the Ministry of Health. Future challenges for the Turkish health care system include, reorganizing and enforcing a referral system from primary to higher levels of care, improving the supply of health care staff, introducing and extending public hospital governance structures that aim to grant autonomous status to public hospitals, and further improving patient rights.