Table 1 The Italian NHS: key features and recent reforms

Foundations

The Italian National Health Service (INHS) was established in 1978 and modelled after the British NHS [21, 22]. Coverage is universal and theoretically uniform throughout the country [21], and both its financing and delivery are mostly public.

Tiers

The INHS has three tiers: Central Government, responsible for guaranteeing essential levels of assistance for every citizen; 21 Regional Governments; and 154 Local Health Authorities (LHAs and 95 Independent SSN Hospitals (or IHs; similar to British NHS Trusts). The LHAs are regional public agencies that manage healthcare services for subsets of the regional population in a defined geographical area. Each LHA serves an average population of about 390,000 inhabitants and manages an average budget of 662 million euros, partly for in-house provision, partly to purchase services from public IHs (on average, 132 million euros per LHA, [23]) and from private contracted providers (on average, 128 million euros per LHA, [23, 24]).

Reforms

Over the last 15 years the INHS has undergone a series of reforms that have introduced quasi-markets, regionalization, and managerialism. A quasi-market system implies that money follows the patient: LHAs pay a provider for their resident’s consumption of healthcare if this is not provided directly by themselves. Patients are free to choose other public or private providers from elsewhere in the country and services are paid for by their LHA [25]. The LHAs are usually funded on a capitation basis and each LHA is expected to reimburse other LHAs, IHs, and accredited private providers for services supplied to its residents [25]. However, regionalization reforms have led to significant variability in how this model is implemented, mainly in the number of facilities directly managed by LHAs, in the degree of autonomy of LHAs in strategic and operational decisions, and in the modification of the capitation funding scheme to match historic expenses.