Try to describe the italian National Health Service to people of other countries is pretty complicated. My purpose by the follow images is to offer a quick frame about it in order to explain how the system is organized and how it works with regard the health services offered to patients.
Italian healthcare is a mixed public-private system even if the public part is absolutely predominant by Italian National Health Service (or SSN – Servizio Sanitario Nazionale), whose purpose is to offer an universal health coverage by tax funding (Beveridge model).
State, by Ministry of Health, rules and coordinates the SSN but the singles Regions have a power so great in regional health organization that is possible to consider the SSN as a system of twenty one different Regional Health Services.Indeed, Regions are like an holding that control two different types of trust on its territory:
- Azienda Sanitaria Locale (ASL): a local health authority that plans and organizes the health and medical assistance to population that lives in its territorial area supplying diagnosis and treatments by public and/or private providers. The ASLs are divided in Distretti (Health Districts) that are responsible for planning the territorial medical assistance, coordinating the GP’s activities with the other health structures on their territory, and supplying some health service (mental health, drug addiction, service for handicapped people and others);
- Azienda Ospedaliera (AO), or simply hospital authority: a trust that manages one or more hospitals. To be an AO is necessary to respect some conditions required by national law. In case that an hospital doesn’t have all these conditions, it is managed directly by the ASL in charge of the territory where the hospital is placed.
Moreover, there are other types of public and private hospitals:
- university hospital authorities named AOUs (they are generally public and managed by university institutions);
- institutes for scientific research and care named IRCCSs (acronym of Istituto di Ricerca e Cura a Carattere Scientifico, and they can be both public and private);
- private hospitals (the most of these are part of the state run health care).
In order to guarantee the essential levels of health assistance provided for by law, each Region can rule own regional health service. In the course of time, four models of organization have been defined to describe how a single regional health service works.
Originally implemented in all Italian regions (except Lombardy), in this model ASLs provide all the health services concerning the territorial medical and diagnostic assistance. Hospital assistance service is guaranteed by the hospitals managed directly by the ASL and the hospitals controlled by one or more AOs, AOUs, IRCCSs or private hospitals. So, regarding the hospital care, the single ASL has a double function:
- to directly provide a hospital assistance by own controlled hospitals;
- to fund all the hospital services that own patients received from AOs, AOUs, IRCCS and private hospitals (in this last case only for hospitals that are part of the state run health care).
Currently this model is used by the most part of the Italian Regions (Aosta Valley, Liguria, Friuli-Venezia Giulia, Trentino South Tyrol, Umbria, Marche, Lazio, Abruzzo, Campania, Apulia, Basilicata, Calabria, Sicily, Sardinia).
It was used only by Lombardy and now it is adopted in no region because Lombardy has reformed its regional health service during 2015. Also in this model the ASLs provide all the health services concerning the territorial medical and diagnostic assistance, but unlike the previous one, they don’t control any hospitals and for this reason offer no hospital assistance. Indeed, the hospital services are provided only by AOs, AOUs, IRCCSs and private hospitals leaving to ASLs the role to fund, to control and to plan them. More briefly, we could assert that the ASLs pay and hospitals provide.
It’s used by two Regions (the first was Marche followed after some years from Molise), and works as the first one: ASLs provide directly the medical and diagnostic assistance, while hospital assistance is guaranteed by hospitals controlled by ASLs, AOs, AOUs, IRCCSs and private hospitals. The big difference between this model and the “classic” one is the number of ASLs on the regional territory: in this case for each region there’s a single ASL that controls own hospitals by some specific territorial areas.
It has the same layout of the classic one, but there are some intermediate authorities between the regional authorities and the ASLs named “Aree Vaste” (Extended Areas). The Aree Vaste’s functions are related to purchases (drugs, devices and other non-medical goods), logistic, information technology, financial administration and human resources, while the ASLs are directly responsible only for health services. According to this framework, a single Area Vasta manages the activities previously listed for a group of ASLs and also for the AOs placed in the Area Vasta’s territorial area, while relationships with others types of providers (IRCCS, private hospitals, etc…) are the same of the classic model. This framework was originally applied in Tuscany, and today is implemented in Emilia-Romagna, Veneto and Piedmont as well.