La bella Italia
Boasting a National Health Service similar to that seen in the UK, Italy’s healthcare system is renowned as one of the best in the world. Tatum Anderson takes a look at the treatment tourists can expect if they fall ill in the heart of European culture.
First published in ITIJ 111, April 2010
Boasting a National Health Service similar to that seen in the UK, Italy’s healthcare system is renowned as one of the best in the world. Tatum Anderson takes a look at the treatment tourists can expect if they fall ill in the heart of European culture.
Italy is known for many things, not least its multifaceted landscape – from the Alps and lakes in the north, to the Mediterranean islands of Elba, Sardinia and Sicily in the south. Add to this the great historical and cultural centres of Rome and Florence and the enclaves of San Marino and the Holy See, a papal state mostly enclosed by Rome, it is, therefore, unsurprising that Italy attracts so many tourists. Italy, in fact, was the fifth-most-popular destination to visit in the world in 2008, receiving a staggering 43.7 million visitors. Up to five million British visitors typically visit Italy each year, although the economic climate has brought with it a decline in the total number of tourists in Europe.
As the world’s eighth-largest industrial economy, and a member of the European Union, tourists can generally expect to encounter one of the best healthcare systems in the world, according to the Organisation for Economic Cooperation and Development (OECD). The country spent 8.7 per cent of its gross domestic product (GDP) on health in 2007 – slightly less than the OECD average of 8.9 per cent. The country also spends less per capita than the OECD average.
Public provision
Italy’s National Health Service (NHS), or Servizio Sanitario Nazionale (SSN), is based on the British system. Introduced in 1978, it provides universal coverage and comprehensive healthcare free of charge, or at a nominal charge upon delivery. It is more decentralised than the UK’s NHS, however, and has an internal market that comprises, in part, a number of private, accredited health facilities. With three levels, the SSN has a central government controlling 20 regions, and within those regions, local health authorities called Azienda Unità Sanitaria Locale (ASL). It is the ASL that set the prices for outpatient and inpatient services in hospitals under their jurisdiction – this means any number of public health facilities can be run by different local government organisations.
Three different companies run the City of Florence’s public health service, for instance. The local health authority of Florence, Azienda Sanitaria di Firenze, oversees Santa Maria Nuova, Nuovo San Giovanni di Dio (Torregalli), Santa Maria Annunziata (Ponte a Niccheri - Bagno a Ripoli), Serristori (Figline), Ponte Nuovo and Orbatello hospitals. But two other groups, called Azienda Ospedaliera Careggi (AOC) and Azienda Ospedaliera Meyer run other institutions from Careggi hospital to Centro Traumatologico Toscano (CTO). And, like the UK system, the Italian national health service is huge. In 2002 there were almost 650,000 employees, over 1,000 hospitals, and 16,000 ambulatory facilities.
people suffering from life-threatening conditions such as heart attacks or strokes have reportedly lower mortality rates in Italy than most other OECD countries
The good news for visitors is that Italy does well in terms of primary healthcare. People suffering from life-threatening conditions such as heart attacks or strokes have reportedly lower mortality rates in Italy than most other OECD countries (apart from the Nordic states). Italy also manages chronic conditions such as asthma, chronic bronchitis and diabetes well too, avoiding many hospital admissions.
Italians will generally receive healthcare free or at a reduced cost. Tourists, primarily those with a European Health Insurance Card (EHIC), will be treated similarly and so will some non-EU citizens with the right documentation. Tourists from countries such as Switzerland and Norway as well as Australia, which has a reciprocal agreement with Italy, can also expect free or reduced-cost services. Citizens of New Zealand, the US, Canada, and other countries must pay for all services. The US state department advises US citizens that patients in private hospitals are generally required to pay fees upfront before leaving the hospital. (Patients with insurance may subsequently seek reimbursement from their insurance companies.)
Despite a National Health Service, not all healthcare is completely free for Italians. The country runs a co-payment system, which means residents must sometimes make small contributions to a pre-determined range of services. Only those with certain exemptions, such as patients on low incomes or with particular conditions such as asthma, do not have to pay. Services that might require co-payment can include, for example, outpatient treatments such as consultations, tests and operations. But, although most emergency services are free, co-payments can sometimes be levied within accident and emergency (A&E). Whether or not co-payments will be charged depends on the access code patients are given at triage within A&E.
Tourists are expected to co-pay too. “Let’s say that if I need an exam I have to pay part of that exam as the ASL will not cover the full cost for me, so the ASL will not cover the full cost for the tourist either,” says Alessandra Busilacchio, operations manager at Sanitrans Assistance, a company with a network of trusted doctors and small medical centres. Tourists must also pay for some ambulance transfer services, too.
Patient pick up emergency ambulance services in Italy comprise a combination of volunteer organisations and private companies that are co-ordinated via the emergency medical service number 118 – although this is soon expected to become 112 in accordance with EU directives. Some of those organisations include Green Cross and Red Cross Ambulance services, as well as ANPAS, a federation of 850 associations with 100,000 Volunteers and 2,700 Ambulances. Consequently, while Mondial Assistance believes it is rare for tourists to be charged for emergency transport hospital, others – including the UK's NHS – say charges for ambulance travel will vary depending on where tourists are and that this is non-refundable in Italy. Payment is often expected for non-urgent transfers, and tourists can usually expect to be transported to accident and emergency (A&E) departments at public or accredited private institutions, although residential standards within hospitals will vary.
Generally, the country’s older public hospitals may still have large wards, however, many of these are disappearing. In newer or refurbished institutions, most rooms are doubles except for specialist and intensive care wards. Because of the complicated public and private system, some major hospitals can be private, but are accredited and work with the government – in 2002, only about 15 per cent of the Italian population had complementary private health insurance either individually subscribed or offered by employers.
although air ambulance services can be provided through a network of government agencies … assistance companies say they prefer to use air ambulance services from outside the country
Milan’s San Raffaele, where Prime Minister Silvio Berlusconi was recently admitted after an attack with a model of a cathedral, is an excellent private hospital, according to experts. However, it also has an A&E department and has dedicated wards for SSN admissions. Private hospitals are run by limited companies or non-profit organisations, although a few are still run by Catholic associations, such as the Pope’s hospital of choice, Gemelli Polyclinic in Rome. Private institutions tend to have excellent accommodation, sometimes comparable to five-star hotels.
But, while the residential quality of private hospitals is better, the medical care is likely to be similar to that of public hospitals. “Clinical quality has to be assessed according to the patient’s illness. Most, if not all, of the sophisticated equipment is in public hospitals,” said Dr Giuseppe Ardoino, deputy medical director, Mondial Assistance, Italy. The costs of private hospitals are in line with the average European tariffs in private hospitals, he continued. Private fees are generally higher than public hospitals and some fees may be refunded direct from ASLs. Other institutions recommended by Sansitrans include the new Ospedale dell’Alngelo in Mestre Venezia and the CTO in Turin.
Treatment options
Beyond the traditional major hospital system, there are several other types of healthcare facilities that serve tourists. One of these is Guardia Medica, a national service that replaces general practioners when not in service – from 8.00 pm to 8.00 am and 24 hours on Sundays and public holidays. This is a basic medical service for non-urgent medical cases and home visits can be arranged, although a payment of €35 is requested for tourists. In 2002, there were 3,036 Guardia Medica stations employing about 18,000 doctors in Italy. Many airports and train stations also have medical teams and limited first aid facilities too.
Likewise, although air ambulance services can be provided through a network of government agencies, including the Italian Coast Guard, Civil Defences and the Carabinieri, assistance companies say they prefer to use air ambulance services from outside the country. Mondial Assistance Italy said that there is currently only one commercial Air Ambulance company in Italy that it is aware of: “We currently use Austrian suppliers for this [air ambulance] service and European Air Ambulance, in line with internal company agreements,” said Ardoino. The US state department stated that family members are usually allowed to accompany the patient on flights and that costs can vary from US$40,000 to $80,000 dollars. Some commercial airlines, such as the national carrier Alitalia, also provide stretcher services.
Some ASLs lay on tourist health services too. Based at Nuova Regina Margherita hospital in Trastevere, Rome, Guardia Turistica is a first aid and emergency medical centre for tourists that is only open during the week, while in Florence, a 24-hour Tourist Medical Service boasts doctors who speak English, French and German. The service can also arrange to see patients at the surgery or make house calls; however, neither Mondial nor Sansitrans use these services.
In ski resorts, including Livigno, Canazei and Sestiere Courmayeur, there are public trauma clinics that specialise in emergency orthopaedic treatment. According to Sanitrans Assistance, there are usually a couple of orthopaedic specialists and nurses based at these trauma clinics, although no major surgery is performed there. Patients requiring major surgery are usually taken to private clinics in towns such as Sameden, Bolzen, or Turin (depending on the ski location) or public hospitals, depending on their choice and insurance. Public hospitals and private trauma clinics can usually be found in the same areas. Some ski resorts, however, provide ski passes that actually include low-cost insurance. In the Aosta region, for instance, anybody with a ski pass is entitled to access to an on-site private emergency service, comprising of an orthopaedic doctor and nurse. If patients cannot be treated here, they are usually transferred to Aosta public hospital. “If the waiting list is too long then the patient can be taken to a private clinic near Aosta at quite a high cost,” said Busilacchio.
Specialist tourist health services can be particularly helpful outside major centres such as Rome, Florence, Venice, Milan and Turin because, in many places, languages other than Italian are not widely spoken. While in hospitals of other major global cities there are offices with English or French-speaking staff who deal specifically with foreigners, this is not usually the case throughout Italy. In some regions, however, such as ski resorts in parts of the alpine Trentino-Alto Adige region, the most northerly in Italy, people tend to speak a mixture of German and Italian. “Language could be a problem,” said Mondial’s Ardoino. “Nevertheless, many doctors speak English and/or French. Some of the younger nurses speak English because it’s part of their degree course, as per EU regulations,” he added. Standards of care are not even across the country, however.
if patients are in remote locations, insurance companies often prefer to repatriate patients directly to their home countries by air ambulance
There are different strategies used to deal with clients on Italian islands, depending on the patient's condition, their level insurance cover and services available. It is sometimes possible leave the islands by air, however, if there are no stretcher flights or if the insurance company is providing lower cover, it is also possible to use a ground ambulance, via ferry. It is not recommended to move clients between Sicily and Rome by ground ambulance, either. If patients are in remote locations, insurance companies often prefer to repatriate patients directly to their home countries by air ambulance. Assistance companies say they often handle transfers via ferry and water ambulance and road to airports in such cases. In Venice, though, access to an intensive care water ambulance can only be done through Suem, the region’s public emergency services.
North versus south
Italy may have one of the best healthcare systems in the world, according to a 2000 World Health Report, which ranked the Italian healthcare system second among 191 countries; it has variable standards of treatment. There is an enduring and obvious disparity between the north and south of Italy – the north is the richest part of Italy, with the best farmland and largest industrial centres. Southern Italy, on the other hand, is poorer and less developed. Two-thirds of all poor Italian families reside in the south of the country. Of the 20.7 million people (36.1 per cent of Italians) living in southern Italy in 2005, 7.3 million (35.4 per cent) were living on less than €521 per month. “With such an economic profile, if southern Italy was thought of as an independent European country, it would be the European country with the highest poverty rate,” reported Maurizio Bonati, head of the Mother and Child Health Laboratory at the Mario Negri Institute of Pharmacological Research in Milan, at the time.
The regional variation in economic development is also evident in Italy’s healthcare services, perhaps reflecting the decentralisation of the country’s political system, and levels of satisfaction with those services. A report looking into satisfaction with the performance of the Italian NHS found that satisfaction levels were only 19 per cent in Sicily, in the south, and 53 per cent in Emilia Romagna, a northern region. To be fair, Italians have historically expressed the highest amount of dissatisfaction with efficiency and quality of its entire health service, despite the country’s high ranking in Europe.
For tourists, however, this means a disparity in many of the hospitals. Assistance companies agree that the total number of hospitals, clinics and personnel is certainly higher in the north than in the south, but this also mirrors the population density. But, the reality is there is less money to spend in southern areas, commented Sanitrans. “The gap is really the amount of money that hospitals can invest in infrastructure, and yes, the gap is there for all to be seen ... older structures, crowded hospitals,” says Busilacchio. That said, if a hospital isn’t suitable, the A&E service ‘118’ can arrange for a transfer.
while the residential quality of private hospitals is better, the medical care is likely to be similar to that of public hospitals
In many ways, not least from a healthcare point of view, Italy is a complex and varied country with many ways of reaching the same conclusion, and it is clear that it is the better assistance companies who are able to skilfully navigate the myriad of different options to get the best health outcomes for their patients, at the lowest cost.