1.3. Political context

The Italian state is a parliamentary, democratic republic with a multi-party political system. Italy has been a democratic republic since 2 June 1946, when the monarchy was abolished by a popular referendum. The basic principles of the Republic are stated in the Constitution enacted in 1948. Article 32 of the Constitution is dedicated to health and health care as it states that “The Republic protects health as a fundamental individual right and societal interest, and ensures free care to indigent people”. It also adds that “Nobody can be administered a compulsory health treatment unless based on the law”.

The main elements of the Italian political system are as follows.

• The President of the Republic, who is the head of state, and is elected for seven years by the Parliament and representatives of the regions.
• The Chamber of Deputies and Senate, which form the bicameral parliament and whose members (400 and 200, respectively) are directly elected for five years by universal suffrage. They exercise legislative power.
• The Prime Minister and the Cabinet, who exercise executive powers. They are appointed by the President of the Republic and must be endorsed by both the Chamber of Deputies and the Senate.
• The judiciary system, which is independent of the executive and the legislative branches.

Since the foundation of the Republic, Italian politics have been characterized by high rates of government turnover, with 67 governments since 1946 (as of 2022).

Italy’s regions are extremely varied. They differ in size (Piedmont is 25 000 km², while Valle d’Aosta is only 3000 km²), population (Lombardy has 15% of the total population, whereas Molise has less than 1%) and levels of economic development. Each region is governed by a Regional Council and its President, both of which are democratically elected every five years. The regions have exclusive legislative power over specific issues designated to them while, for several other issues, authority is “concurrent” with the central government (Italian Constitution art. 117). However, regions’ financial autonomy is quite modest: they hold 20% of all levied taxes, mostly used to finance the regionally based health care systems. The fiscal system is centralized. Cooperation between the activities of the central government and those of the regions is organized through a permanent body, the Standing Conference of the State, Regions and Autonomous Provinces (or the State-Regions Conferences, for short).

The regions are subdivided into 86 provinces (UPI, 2019) that used to be governed by democratically elected councils but in 2014 were transformed into administrative bodies with limited competences, with Provincial Presidents (executive power) and Councillors (legislative power) elected by mayors and councillors of the municipalities of the province (Law 56/2014). However, provincial districts are still important because for each of them the national government appoints a prefect who acts as a delegate, representing the central government on a number of matters in each province. The basic unit of local government is the municipality (comune), which may range in size from a small village with less than 100 inhabitants to a large city such as Rome. Italy has about 8100 municipalities, and only 8% have over 15 000 inhabitants. A mayor and a council are elected for a five-year term to govern each municipality.