4.1. Physical resources

4.1.1. Infrastructure, capital stock and investments

Infrastructure

In Italy in 2017, 51.8% of health care facilities were public, while accredited private facilities accounted for the remaining 48.2%, with a high concentration in the regions of Lazio, Lombardy, Campania and Sicily (ANAAO-ASSOMED, 2020).

In 2019, the SSN had almost 190 000 ordinary hospital beds, 21.4% of which were in accredited private facilities. In addition to these, there were 12 173 day hospital beds, which are almost entirely public (83.8%), and 8389 day surgery beds, which are mostly public (76.2%). At the national level, 0.6 beds per 1000 inhabitants were allocated to rehabilitation and long-term care, with considerable regional variability. Following similar trends in OECD and EU countries, the number of acute beds in Italy has decreased, falling by 39% since 2000 (from 422 per 100 000 people to 260 in 2019) (Fig4.1; see also Table5.1).

Fig4.1	Table5.1

Such numbers result from a progressive reorganization of the hospital network in response to rising financial constraints and the search for quality improvements. With Ministerial Decree 70/2015, which set targets based on “catchment areas” and regulated hospital care standards, the government entrusted regions to identify hospitals or wards to be closed and incentivized the provision of outpatient care (see Chapter 6). However these efforts to reinforce outpatient networks of care were heterogeneous among the regions. In 2020, the declining trend in hospital beds was reversed as the number of intensive care unit (ICU) beds almost doubled in a few months due to the COVID-19 emergency.

Current capital stock

In 2019, Italy’s health care infrastructure comprised 995 hospitals, 8801 outpatient centres, 1145 rehabilitation facilities, and 16 270 residential and semi-residential establishments. Hospitals and outpatient care facilities are mostly public (51.8% and 87%, respectively) whereas establishments that provide residential, semi-residential and rehabilitation assistance are mostly private for-profit and not for-profit accredited organizations (Ministero della Salute, 2020c).

Italian hospitals have a mean age of 70 years (de Belvis et al., 2012) and their sizes are as follows: 39% of inpatient facilities have less than 120 beds and only 13% have over 600 beds, with the largest hospitals exceeding 1500 beds, mainly located in the large metropolitan areas of Rome and Milan (see Table4.1 and Box4.1). Generally, the smallest hospitals cover less than 14 specialties, whereas the largest ones cover at least 15 specialties.

Table4.1	Box4.1

Local health authorities provide inpatient care through their own hospitals in most cases. The rest are autonomous hospitals that may also be connected to a university (known as polyclinics). Italian legislation also distinguishes 40 scientific and research institutes, IRCCS nominated by the Ministry of Health if they meet standards of excellence in services and biomedical research (see Chapter 2). These entities, which can include hospitals, are entitled to special public funding earmarked for research. With Ministerial Decree 70/2015, Italy’s health care facilities were reorganized to integrate services and reinforce networks as a means of enhancing appropriateness, effectiveness, efficiency, quality and safety of care (Box4.1).

Regulation of capital investment

Since 2018, a new unit within the Ministry of Health dedicated to the Evaluation and Verification of Public Investments has been responsible for evaluating compliance of capital investment with national health policies and their sustainability in relation to regional economic–financial contexts. Moreover, regional autonomy allows for other sources of funding for health infrastructures, such as using ad hoc regional funds, EU funds and self-financing through hospitals or local health authorities. Health capital spending decreased significantly from 2010 to 2019, but the 2019 Budget Law and the 2019–2021 Health Pact reversed this trend by allocating €4 billion for construction and technological modernization programmes.

Investment funding

Public capital investment funds are assigned in the annual health budget. In 2016, Italian legislators began simplifying tendering procedures to facilitate renovation and innovation initiatives. During 2020 and 2021, the necessity to respond promptly to the demands of the COVID-19 pandemic led to procurement processes (for example, for PPE, medicines, medical devices to be used in ICUs, and vaccines) being radically shortened; this experience may lead to a permanent simplification of the system. Between 2009 and 2018, the health care sector was also reliant on private–public partnerships to fund capital investment, with a slight decrease in this trend more recently.

Starting from 2021, the country’s capital investment, infrastructural modernization and digitalization funds for the health care system are being complemented by the designated NextGenerationEU budget. Reflecting stated policy priorities, the aim will be to strengthen primary and specialist outpatient services, community care and telemedicine services. Additional efforts are also being made towards the energy efficiency of public health care infrastructure with the support of EU funds, the funding under the Kyoto Protocol Convention[10] and private initiatives.

4.1.2. Medical equipment

The use of technical-biomedical equipment is increasing in the public sector and Italy now ranks among the EU countries with the highest volume of MRI units, CT scanners and PET units per capita. For example, together with Cyprus and Belgium, Italy had the most imaging equipment of all EU Member States in 2018, well above the EU average (Table4.2).

Table4.2

Since 2015, the medical devices procurement process can be launched individually by facilities or via a more centralized procedure carried out by the UPCs, under regional guidelines and their decision-making support. Regions’ medical devices procurement databases feed into the Regional Observatories that send the information to UPCs to manage negotiations with facilities (see also section 2.7.5). When awarding the call for tenders, the criteria provide for the evaluation of both quantitative (price) and qualitative elements attributable to the entire life-cycle of the equipment; the most economically valid offer is prioritized. The ongoing centralization process has been shown to hasten procurement processes, especially with larger medical devices, and to contain expenditure. However, purchasing choices appear to be more focused on price considerations than on the quality of the services or clinical benefits (Vecchi et al., 2019). Since 2014, the expenditure cap for medical devices has been set at 4.4% of a region’s annual health care funding.

4.1.3. Information technology and e-Health

The NSIS is the SSN’s primary information system to support national and regional governance, health expenditure monitoring and to guarantee the uniform application of the national benefits package (LEA) (see Chapters 2 and 6). In Italy, the services that traditionally fall under this category are single appointment centres (Centri Unici di Prenotazione, CUP), which enable patients to book appointments online and by telephone; electronic health records (EHRs), electronic medical certificates, e-Prescriptions and telemedicine. Online booking and payments connected to regional platforms and EHRs are present in over 75% of facilities. Through the EHRs, citizens can trace and consult their entire health history and share it with health professionals; however, only a minority of people have heard of them. The information in each citizen’s EHR is provided and managed by the regions. It is currently active in all the regions, yet its full potential still needs to be operationalized as only 21% of the population actually use it.

The National Waiting Lists Plan 2019–2021 (Piano Nazionale Governo delle Liste di Attesa, PNGLA) requests regional CUP, which centrally manage the timetabling of appointments of all SSN facilities, to provide online services allowing people to view and cancel appointments, pay for services, print memos and also view waiting lists in real time. In addition, IT supports over 60% of health facility activities, mostly for diagnostic imaging – particularly for radiology, tests and surgical operating rooms. Digital treatments to remotely monitor adherence to therapy are mostly used for the management of chronic diseases such as diabetes and heart failure (Sanità Digitale, 2019).

In recent years, digital health spending for electronic medical records in health care facilities has been growing (by 2% in 2017 and 7% in 2018), with the largest share being sustained by facilities and regions. Until 2019, digital innovation expenditure mostly focused on the aforementioned services, with the rest funding pilot projects. With the COVID-19 outbreak, legislative changes inserted telehealth services into the list of reimbursable services, with new codes and tariffs being issued to formally integrate remote services into the SSN. Nevertheless, the pace of innovation in this area generally has been slow (Sanità Digitale, 2019). Although the number of tenders for digital innovations has been increasing since 2016, health care companies have found the process difficult, mainly due to the rigid structure of the tendering framework and complex legislation. At the EU level, the significant resources invested with the NextGenerationEU budget present an opportunity to drive the digitalization of health care processes and e-Health, with room for policy development also offered by the NRRP. The latter channels investments into the digitalization of care, further promoting the development of EHRs and telemedicine in both health care and preventive services. Box4.2 outlines some of the barriers to innovation in this area.

Box4.2

From the consumers’ point of view, access to digital services, including apps and wearables, has significantly increased despite such data seldom being communicated to doctors. While Italian citizens increasingly resort to the Internet and digital tools to find health information, the opinions of GPs are still considered to be fundamental when choosing a specialist, followed by those of relatives and friends. When it comes to information on institutional websites, online opinions and reviews are considered not to be relevant (Sanità Digitale, 2019). Since the COVID-19 pandemic (2020), use of the Internet for information on pharmaceuticals/therapy, health issues, diagnoses based on symptoms and healthy lifestyles has increased, mainly extracted from institutional websites and medical portals. Apps, blogs and social networks are used mainly for information on lifestyles and nutrition.