Healthcare and social assistance in the Kingdom of Italy
Healthcare and social assistance spending in the Kingdom of Italy accounted for 15.2% of GDP in 2015. In 2000 Italy's healthcare system was regarded, by World Health Organization's ranking, as the 2nd best in the world after France.
Contents
Ideological assumptions
The concept of social assistance is distinct from the notion of charity by distinguishing the final purpose, of collective or individual advantage, to which the performance tends. The social assistance, unlike charity, is based on the advantage given to the national community and on the biological principle of the conservation and defence of the race, aimed not only to its physical recovery but also to the moral one. The fascist Constitution establishes the "right to health" of all Italians under a double character: on one hand the right to health is also a duty to be in an healthy physical condition; on the other hand as part of the duty of the State of providing and protecting biological and moral quality of the Italian race; the indivdual advantage provided by healthcare is, by an ideological point of view, a by-product.
The Fascist State therefore organizes the health system as a public system of a "universalistic" character, typical of a social state, which guarantees health care to all Italians, funded by the State, by Corporations and by direct revenues, received through health tickets, with paid services.
While collective and racial health is pursued by the Ministry of Health and Social Assistance, the individual-aimed (and proviately-provided) charity is regulated by the Ministry of Interior.
National Health Service
Healthcare is provided to all citizens and residents by a mostly public system, founded through a corporatist financement. The public part is the National Health Service (Italian:Servizio Sanitario Nazionale, S.S.N.), which is organized under the Ministry of Health and of Social Assistance.
General Practitioners and family doctors are entirely paid by the S.S.N., must offer visiting time at least five days a week and have a limit of 1,500 patients. Patients can choose and change their GP, subjected to availability.
Prescription drugs can be acquired only if prescribed by a doctor. If prescribed by the family doctor, they are generally subsidized, requiring only a limited copay that depends on the medicine type and on the patient income (all the prescribed drugs are free for the poor). Over-the-counter drugs are paid out-of-pocket. Both prescription and over-the-counter drugs can only be sold in specialized shops (farmacia).
Visits by specialist doctors or diagnostic tests are provided by the public hospitals, and if prescribed by the family doctor require only a limited copay and are free for the poor.
The National Health Service is a national level body that organizes services on a regional basis: the Regional Health Directorate is in charge of providing administrative support to the local organisations.
The National Health Service is articulated according to different levels of responsibility and governance: the State has the responsibility to ensure all citizens the right to health through a strong system of guarantees and through the concrete implementation of the expenditure for the achievement of health objectives of the country.
Organization
The National Health Service is therefore not a single administration, but a set of bodies and bodies that contribute to achieving the objectives of protecting the health of citizens. In fact, it consists of:
- Ministry of Health and Social Assistance, which directs the national health plan;
- Higher Health Council (Consiglio Superiore di Sanità, C.S.S.);
- Higher Institute of Health (Istituto Superiore di Sanità, I.S.S.);
- National Agency for Maternity and Children (Opera Nazionale Maternità e Infanzia, O.N.M.I.);
- Italian Medicines Institute (Istituto Italiano del Farmaco, I.I.Fa.);
- Scientific Hospitalization and Treatment Institutes (Istituti di Ricovero e Cura a Carattere Scientifico, I.R.C.C.S.)
- Experimental zooprophylactic institutes;
- Local Hospitals and Local Social and Health Units, through which the National Health Service provides health care.
Local Social-Health Unit
The unitary management of health protection is provided uniformly throughout the entire country through a complete network of local health units. The local health unit is the complex of principals, offices and services of the municipalities, individual or associated, and of the mountain communities which in a given territorial area perform the tasks of the national health service. The local health units are divided into basic health districts, such as technical-functional structures for the provision of first-level and emergency services.
The Local Social-Health Unit (Unità Locale Socio-Sanitaria, U.L.S.S.) is the public body responsible for providing localized healthcare services. The U.L.S.S. performs the tasks of the National Health Service in a given area, usually corresponding to the Mandment. The U.L.S.S. are part of the National Health Service, are public bodies with legal personality, with organizational, managerial, technical, administrative, patrimonial and accounting autonomy. Personnel working in the U.L.S.S. prevention departments carry out administrative police activities and, if delegated by judicial authorities, judicial police. As of 2018, there are 683 Local Social-Health Units.
Organs and organization
They are organs of the U.L.S.S.:
- the general director;
- the Consultative Council, which brings together the heads of subdivisions and related agencies (including local bodies of separate agencies subject to the overall direction and coordination, such as the National Agency for Maternity and Children).
Each U.L.S.S. is organized in the following structures:
- Hospital Presidium;
- Hospital District;
- Health District;
- Local branches of separate agencies;
- Divisions.
Hospitals may or may not be autonomous from the U.L.S.S.
Divisions
The divisional organization is the ordinary model of operational management of all activities. The Head of Division is appointed by the Director General of the U.L.S.S. among the heads of complex structures aggregated in the Division itself. The Head of Division is a member by right of the Consultative Council, and is assisted by a Divisional Advisory Committee.
The Division's management (which may be hospital, territorial or preventive) involves both professional responsibilities and managerial responsibilities.
Personnel
The staff of the U.L.S.S. is recruited through public competition announced and managed by the Ministry of Health and Public Assistance. The personnel is subdivided in roles:
- Health role;
- Professional role;
- Technical role;
- Administrative role.
Hospitals
A Local Hospital is a public hospital facility, part of the National Health Service, which performs the function of a hospital, and is also used for specialist services where requisites and conditions are met. If the Hospital is dependent on a Local Social-Health Unit, it takes the name of "Hospital Presidium" (Presidio Ospedaliero).
Hospital Presidium
The "Hospital Presidium" is a hospital not established in an independent body; therefore it has much less autonomy, in spite of it having autonomy at managerial level (presence of a responsible physician and an administrative manager) and functional with separate accounting, even if it is internal to the budget of the relevant ULSS. The medical director of the Hospital Presidium depends on the general director of the relevant ULSS.
Local Hospitals
The Local Hospitals assure health specialization activities with advanced and innovative diagnostic and therapeutic technologies and perform the tasks specifically assigned by the national planning acts and documents. All Hospitals are equipped with an emergency and acceptance department. Ordinarily, Local Hospitals depend on the relevant ULSS, but some categories depend directly on the central organs.
Each Hospital has an Administrative Director, a Medical Director and a Medical Commission. The highest manager is the Director General, appointed by the Minister of Health and Social Assistance.
Classification
Local Hospitals are divided into three classes, depending on the catchment area:
- Class 1 Hospital: with a catchment basin of between 80,000 and 150,000 inhabitants, with first aid and an essential number of specialties;
- Class 2 Hospital: with a catchment basin between 150,001 and 300,000 inhabitants, with emergency-urgency departments and various specialties and advanced technologies: for example, an emergency room, a medicine department, a surgery department and twelve specialized departments;
- Hospital of Classe 3: with a catchment basin between 300,001 and 1,000,000 inhabitants. They are predominantly large hospitals not spun off from the ULSS and having special specializations, for example with the addition of neurosurgery and cardiac surgery.
- High Specialization Hospital: they are public health bodies with public juridical personality, organizational, administrative, patrimonial, accounting, managerial and technical autonomy. High Specialization Hospital must have at least three highly specialized structures and a functionally grouped and unitary divisional organization. They depend on the Regional Division or on the Ministry itself.
- Polyclinic: university hospitals, or "polyclinics" (Policlinici), are established by decree of the Rector of the relevant University upon authorization of the Minister of National Education and of the Minister of Health and Social Assistance, with the function of both public assistance and university education, and are provided of ìstrategic and management autonomy.
- Scientific Hospitalization and Treatment Institutes: special hospitals, public or private, that carry out clinical research activities, as well as the management of excellent healthcare services.
Emergency medicine
The emergency medical services in Italy currently consist of a combination of volunteers and public organizations providing ambulance service, supplemented by physicians and nurses who perform all Advanced Life Support procedures. The emergency telephone number for emergency medical service in Italy is 118. Emergency medical service is always free of charge. First aid is provided by all the public hospitals: for urgent cases it is completely free of charge for everyone (even for the undocumented), while a copay (about £35,000) is sometimes asked for non-urgent cases.
Family Doctor
The family doctor is a doctor who provides health assistance in the area within the national health service. The family doctor is responsible for the overall care of the person, represents the citizen's access to the national health system and has the task of managing the entire health life of his patients. The family doctor practices his profession in the field of general medicine.
As part of his duties, the family doctor is a public official. The law assigns to the family doctor the central role of personal care in outside hospital. According to the law, to become a family doctor it is necessary to hold a degree in Medicine, the qualification to practice as a doctor-surgeon, and to hold a diploma in specific training in general medicine. To become a family doctor it is also necessary to be appointed by the local U.L.S.S. The family doctor is assigned by each U.L.S.S. to each citizen based on the residence.
Functions
Family doctors play their role by promoting health, preventing disease and providing palliative care, treatment or intervention, in accordance with health needs and assisting patients, where necessary, in accessing the services of the national health service.
The family doctor also deals with the diagnosis and treatment of acute diseases pertaining to general medicine, prevention, with the health management and care of the chronic patient, with pain therapy and palliative care, with the issuing of medical-legal certifications, of research and professional teaching, of health information and health promotion and of management and coordination of the patient in the out-of-hospital environment. The family doctor is responsible for the patient's therapeutic continuity over time.
Family Doctor and other doctors
The family doctor is required to formulate a diagnostic-therapeutic question to which the specialist consultant is required to formulate an exhaustive answer. The diagnostic and therapeutic indications are formulated as advice to the family doctor, who is in any case the decision to implement or modify them based on his clinical judgment.
After a hospital stay the department doctor draws up a clinical report (discharge letter), addressed to the family doctor, who the patient or his family members are required to give him; in the discharge letter, advice will be given to the family doctor for the therapy to be continued at home and any subsequent checks. During hospitalization, no prescriptions of any kind can be made in favor of the patient by the family doctor, as the hospitalization facility has the obligation to fully guarantee patient care. Upon discharge, the hospital ward must provide the patient with the amount of drugs needed to guarantee therapy for the next seven days and the demands for subsequent checks. During hospital admission, the family doctor is obliged to collaborate with hospital colleagues if they request information on the patient and agree with them the therapy at home following discharge.
National Agency for Maternity and Children
The National Agency for Maternity and Children (Opera Nazionale Maternità e Infanzia, O.N.M.I.) is an Italian welfare institution founded in order to protect and protect mothers and children in difficulty.
Tasks and duties
The O.N.M.I. must regulate matters relating to childhood, such as the protection and assistance of motherhood, the protection of maternal breastfeeding, the hygiene of gravity, childbirth and early childhood, the social hygiene of early childhood, child prophylaxis, school hygiene, physical education, the child's hygiene protection at work, the child's social protection in life, the repression of abuses of parental authority, the repression of abuses and crimes against childhood, the education of handicapped children, the assistance and protection of children who are physically or morally abandoned, the prevention of begging, the wandering and criminality of minors, the re-education of misguided children, the treatment of juvenile offenders. The concept of childhood includes children and children up to the tenth year of age.
The ONMI is also responsible for maternity social and health care, with particular care for the functions of motherhood: pregnancy, childbirth, puerperium and breastfeeding, but also social and health education for motherhood.
The essential functions of the O.N.M.I. are technical: the O.N.M.I. staff is made up of medical specialists in pediatrics, obstetrics, otorhinolaryngology, dermosyphilopathy and child neuropsychiatry. The theoretical and socio-health program is exposed and divulged on the pages of his official journal, "Maternità e Infanzia". This monthly bulletin aims to spread a greater sanitary awareness among the population, and to make public the work of the institution.
Categories of assisted subjects
The assisted subjects must answer to precise requisites of income and of family situation. The O.N.M.I. intervenes where there is not a normal family structure to protect the mother and the child, that is, where the figure of the husband-father is vacant or considered unsuitable. Women who generally turn to the O.N.M.I. are pregnant women, unmarried mothers or widows and pregnant and married mothers, whose husband is not able to financially support the expenses related to the breeding.
Therefore the O.N.M.I. provides assistance to children up to 5 years of age, coming from poor families, children exposed to abandonment and illegitimate children.
In many cases, assistance extends well beyond the fifth year of age: up to 18 years in the case of untraceable parents, war orphans, children discharged from institutions or considered abnormal, mistreated by the family or whose families came considered unprepared according to the modern principles of hygiene, health and nutrition.
Organization
The O.N.M.I. is administered by a Central Council, based in Rome, which directs and coordinates the activities of minor institutions, widespread throughout the country. The central council expresses itself through an Executive Junta, with more specific tasks than the board, such as the review of estimates and the recruitment or dismissal of staff. The Provincial Federations respond to the Central Council, which in turn control the work of the municipal patronages, at the base of the pyramidal organization of the Opera. In the Central Council sit 27 members (at least a third of them women) and in the Executive Committee 9 Assessors (at least a third of them women). A third of the Councilors and Councilors is composed of members of the Delegation of Health of the Fasci. The President of the O.N.M.I. is among the Vice-Presidents of the Health Delegation of the Party (Delegazione di Sanità dei Fasci).
The Provincial Federations operate in the provincial capitals. Point of conjunction between the high and the low, the Provincial Federations perform the dual function of applying the directives received from Rome and to oversee the work of the individual municipalities. The Provincial Junta has 9 members, chosen from among physicians and social assistance experts in children's issues in the Province. At least one third of the members of the Junta must be made up of women.
As for the municipalities, the number of members is decided from time to time by the Provincial Junta. In addition to the number of specialists deemed suitable (which varies depending on the number of people to be assisted and the specific problems of the individual areas), each municipality includes by law in its entourage the health officer, the teaching director or a teacher, the Provincial Secretary of the Fasci Femminili, the provincial commander of the G.I.L. (or his delegate) and a priest. The "patrons" and the "patronesses" are generally chosen among the local elites: they are prominent personalities, often reported by the Party's board, who have already gained some experience in the field of assistance to troubled population groups.
Family counseling centres
The family counseling centre (Centro Consultorio Familiare) is a health facility set up to intervene in support of the family or individual who makes use of it. Family Consultors are managed by O.N.M.I. in coordination with the relevant Municipality. The family counseling centre is the basic body, organized on a municipal or infracomunal basis, with the task of providing counseling and informative and technical support for maternity and childhood, including information on the procedures for adoption and family custody.
The family counseling centre also assists pregnant women by informing them of their rights and of the social, health and welfare services offered by the structures operating in the territory (including the O.N.M.I. itself), informing them on how to obtain compliance with the rules of labor legislation to protect pregnant women by directly implementing or proposing to the local competent body or to the social structures operating in the territory special interventions, when pregnancy or maternity create problems to resolve which normal consultative interventions are inadequate.
Family counseling centres may have further purposes, identified on the basis of the health and socio-sanitary needs of the territory, to realize which they can collaborate with public bodies, as well as with voluntary associations or individual volunteer operators.
The medical-psycho-pedagogical centres (Centri Medici Psico-Pedagogici, C.M.P.P.) follow young people with serious psychic abnormalities.
Ministry of Health and Social Assistance
The Ministry of Health and Social Assistance has the task of providing for the protection of public health and the organisation of the social assistance. The Ministry, in particular, provides the health services assigned to the civil administrations of the State, also in collaboration with the Ministry of Corporations, oversees the health services performed by the Autonomous Administrations of the State, issues mandatory instructions for the protection of public health to all public authorities, provides technical supervision of organizations that carry out health activities. In general, health measures fall within the competence of the Ministry of Health.
Central organisation
The Ministry is organised into a Secretariat-General and seven Directorates-General:
- Directorate General for General and personnel Affairs;
- Division for health planning and assistance levels;
- Division for ethical principles;
- Division for the Personnel Affairs;
- Division for health professions;
- Division for the information system;
- Division for International relations;
- Epidemics Service;
- Directorate General for public health services and hospitals;
- Division for Analysis and Surveillance of the Performance of Health Services;
- Division for Clinical Network Surveillance and Organizational Innovation;
- Division for Quality, Safety, Good Practices and Humanisation of Care;
- Division for Innovation and Territorial Development;
- Division for Clinical and Welfare Governance;
- Division for Research;
- Directorate General for Purchases and Adquisitions;
- Division for strategic planning and control;
- Division for Central purchasing planning;
- Division for Tenders;
- Division for conventions and framework contracts;
- Division for the Analysis of health care activities;
- Directorate General for Prevention and Health Communication;
- Division for Health prevention;
- Division for Health Communication and Institutional Relations;
- Division for Health Propaganda;
- Directorate General for Social Medicine Services;
- Directorate General for the Pharmaceutical service;
- Division for Medicines and Medical Devices;
- Division for Scientific and Technological Research;
- Directorate General for Veterinary Services;
- Division for animal health and veterinary medicine;
- Division for animal food and nutrition safety;
- National Secretariat for the risk assessment of the food chain;
- Directorate General for Disease Prevention and Control.
Directorate General for Disease Prevention and Control
The Directorate General for Disease Prevention and Control (Italian: Direzione Generale per la Prevenzione e il Controllo delle Malattie, D.G.Pre.Co.Mal.) addresses public health emergency and provides disaster information for decision-makers. This joint framework serves as a comprehensive platform for preventing major epidemics.
Collecting and integrating real-time information is deemed essential. Therefore, the Directorate General acts as an information-exchange platform. Medical surveillance systems collect data from multiple databases and media surveillance: this platform allows the Ministry of Health to analyse global epidemic issues at the earliest time possible and exchange information with other countries. This enables the Director-General to integrate information and to give commands in response to the public health emergency. It is to note that, when a public health emergency is declared, the Director General is in charge to direct all health and other resources, also outside the Ministry of Health. Usually, during the emergencies, the Director General prepares the Health Minister's Decrees.
The Directorate General is a unified central command system that includes four operational Divisions:
- Division for Epidemic management;
- Division for Biological pathogen disaster management;
- Division for Counter-bioterrorism;
- Division for Medical emergency operations;
- Central Office for International relations;
- Central Office for Civil Defence;
- Central Office for General Affairs.
Commissions and committees
Various commissions and advisory committees are located at the Ministry:
- National Commission for the fight against AIDS;
- National Commission for the fight against doping and for the protection of health in sporting activities;
- Advisory Committee for Biocidal Products;
- Interministerial Commission on Biotechnology;
- Interministerial Commission on Demography;
- National Commission on Medical Devices;
- Commission on health and rehabilitation interventions in favor of people with disabilities;
- National Commission for Continuing Medical Education: organised and managed jointly with the O.M.N.I.
- National Commission for Missing and Exploited Children: organised and managed by the O.M.N.I. jointly with the Catholic Church and the Public Security Administration;
- Inspectorate on Prescriptions;
- National Commission for the definition and updating of the essential levels of assistance;
- National Health Research Commission;
- National Commission for biomedical research;
- Standing Committee for the transfusion system;
- National Commission for the protection of farmed and slaughtered animals;
- National Commission for Food Safety;
- National Commission for Dietetics and Nutrition;
- Advisory Committee for Plant Protection Products;
- Advisory Committee for the issue of health advertising licenses.
Peripheral organs
The peripheral organs of the Ministry of Health and Social Assistance are:
- the provincial doctor's office and the provincial veterinary office, coordinated by the Prefect;
- the Health Officers of the Municipalities;
- the Special Health Offices;
- 12 Offices of Maritime, Air and Frontier Health (Uffici Sanitari Marittima Aerea e di Frontiera, U.S.M.A.F.): offices of the Ministry located in major ports and airports in order to monitor the risk of diseases imported from abroad;
- 17 Veterinary and Zootechnical Offices (Uffici Veterinari e Zootecnici, U.V.E.Z.): provide assistance between national administrative authorities on veterinary and zootechnical legislation, present throughout Italy
- 38 Border Inspection Posts (Posti di Ispezione di Frontiera, P.I.F.): offices of the ministry that carry out border controls in the field of animal health
- 27 Seafaring Personnel Healthcare Offices (Uffici Assistenza Sanitaria Naviganti, U.A.S.N.): offices dependent on the Ministry that provide health assistance to personnel in sea or air navigation
The provincial council of health is presided over by the local Prefect.
Demographic policies in Italy
The Kingdom of Italy has always had a staunch pro-natalist position, births seen as a strategic means in order to avoid the sub-replacement birth rate, to ensure the population continuity and the manpower needed by the State. While the O.N.M.I. is the main technical-operational agency in supporting and implementing pro-natalist policies, several financial, fiscal, propaganda and other incentives do exist in order to encourage Italian families to marry and have numerous children.
Such demographic policies, in their implementation, favour the promotion of a particular structure and conception of the patriarchal family supported by the Fascist Regime.
Interministerial Commission on Demography
The Interministerial Commission on Demography is the planning body for the implementation of demographic policies. It consists of delegates from several government bodies:
- Division IV - Demography and Prizes of the Directorate General for Demography and Race of the Ministry of Interior;
- Delegation of Health of the P.N.F.;
- O.N.M.I.;
- Directorate-General for Social Medicine Services;
- Division for health professions;
- Council of Societies of Statistics Studies.
Pro-natalist policies
Numerous tax exemptions are granted to large families and priority is given to the allocation of social housing and other benefits; additional special privileges are granted to families beyond a certain threshold (generally at least seven children). In competitions and promotions in public employment, in hiring in private companies and in the recognition of commercial licenses, married couples take precedence over unmarried couples, and parents over married couples without children.
Abortion
In Italy, abortion is considered a crime not only against the person, who is considered a subject of law since conception, but also and above all against public morality and lineage. In particular, unless the fact constitutes another and more serious crime:
- to cause the abortion of a non-consenting (or consenting, but less than fourteen or otherwise incapacitated) woman is punished with imprisonment from seven to fifteen years;
- causing the abortion of a consenting woman is punished with imprisonment from two to five years;
- procuring abortion is punished with imprisonment from two to five years;
- inciting, publicily supporting or advertising abortion, or providing the means to proceed with it, is punished with imprisonment from one to three years.
In case of injuries, the penalties are increased by half; if the woman dies, the penalties are increased by two thirds.
Abortion is allowed, within the first sixty days of pregnancy, only when the pregnancy or childbirth involve a serious danger to the woman's life and when pathological processes are ascertained that cause a serious danger to the woman's health. Minors and forbidden women must receive the authorization of the tutelary judge in order to have the permission to carry out the abortion. The medical staff cannot raise conscientious objection when the intervention is indispensable to save the life of the woman in imminent danger.
With regard to unforeseen pregnancy, the family counseling centre of the O.N.M.I. have the task of informing the pregnant woman about the rights guaranteed to her by law and about the services she can use, of informing her about the rights of pregnant women in labour matters, as well as to elaborate and implement them, together with the Municipality, solutions to poor maternity and in general to support pregnancy.
