THE ITALIAN INSTITUTIONAL FRAMEWORK

Italian healthcare has been subject to copious processes of reform and reorganization, which have repeatedly redefined the logical framework that underlies the health system of our country.

The Italian National Health Service (hereafter abbreviated as INHS) inspired by the founding principles of the English National Health Service, is established by Law 833/1978; in this text of the law it lays down its founding pillars of the system, namely the public responsibility for the protection of health, the universality and equity of access to health services, the totality of coverage according to the care needs of each one, the portability of care rights throughout the national territory and public funding through tax revenue (Adinolfi e Melè, 2005; Demasi, 2010)

INHS de facto gives definitive implementation to art. 32 of the Italian Constitution, which identifies the protection of health as a fundamental right of the individual and interest of the community and where the responsibility for achieving this purpose is attributed to the State.

It is therefore implied that the task of the INHS is to prevent, diagnose, treat and rehabilitate (Demasi, 2010).

The Res Pubblica, becomes the protagonist of the health care process, defining the financial burden of expenditure, the essential lines, the size of the offer as well as the laws to which the Regions should adhere and consequently that manage the local health units present in the territory (Ardissone, 2008; Demasi, 2010).

The reform bis De Lorenzo and Garavaglia of the two-year period 1992-93 (Legislative Decree 502/1992 and subsequent Legislative Decree 517/1993) as well as the Bindi reform ter of 1999 (Legislative Decree 229/1999) lead to profound changes compared to the initial founding regulations of the system, giving a clear turn in a corporate sense to health management, through a reconceptualization of the governance of the entire system; this introduces the corporatization of health facilities, their management according to managerial criteria, regionalization, attention to the quality of the services provided, accreditation of hospital facilities, competition between public and private actors, the introduction of supplementary funds, etc., while guaranteeing the concept of health as a collective good (Demasi, 2010).

This two-year period of lively regulatory proliferation, sees the introduction of the ticket, as a participation in the health expenditure requested directly from citizens based on the services requested.

This period of regulatory revolution in the field of health led to the amendment of Title V of the Constitution following the entry into force of the constitutional law of 18 October 2001, n. 3 and the identification of the Essential Levels of Assistance (LEA) with the D.P.C.M. 29 November 2001 with the subsequent additions (Demasi, 2010).

Article 117, paragraph 2 letter m) of the Constitution places on the State the exclusive power in the determination of the essential levels of benefits concerning civil and social rights that must be guaranteed throughout the national territory and the delimitation of the fundamental principles in the matter, to be defined by national law (Demasi, 2010).

The Regions are given concurrent legislative power in the field of: health protection, protection and safety at work, professions, scientific and technological research and support for innovation, nutrition, sports system, supplementary and supplementary pensions, harmonization of public budgets and coordination of public finance and the tax system (Demasi, 2010).

Following the revolution of the logical system of reference, the Central Government and the Regions are entrusted with specific tasks, namely the responsibility of identifying mechanisms to guarantee health protection for the citizen, ensuring universalism and equity of access.

With the introduction of the current framework of health federalism, the burden on the Government is to define a new -large health system, now composed of numerous government subjects, placed in a subsidiary system both in vertical and horizontal terms: all the institutional actors and health workers present in the territory, through different interventions and participations, collaborate in a common integrated prevention project, diagnosis, treatment and rehabilitation of health care for the patient in order to contribute to the realization of favourable conditions for the satisfactory implementation of the right to health (Demasi, 2010).

The INHS – unlike the British National Health Service – is highly decentralised and the 20 regions, as just explained, are each legally responsible for planning services and allocating financial resources (Demasi, 2010).

Local self-government implies financial responsibility, which allows regions to develop health strategies based on their own health needs.

National policy is therefore not taken up in a homogeneous way by all regions.

With the already mentioned reforms of the INHS, launched in 1992 and finalized with "Bindi ter"

(Legislative Decree 229/1999), principles of competition between health service providers have been introduced with the dual objective - to increase the quality of care and contain health

expenditure (Grattini et al., 2020; France et al., 2020; Brenna et al., 2011; Maino et al, 2011;

Demasi, 2010).

The hospital sector sees a radical change at this time: many private suppliers have been accredited to whom, similarly to public healthcare organisations, public funds have been granted for hospital activities provided under the INHS system (Grattini et al, 2020).

Each Region, through its Local Health Authorities (Italian abbreviation ASL, hereinafter Local Health Authority, LHA), is financially responsible for the health services provided to the resident population. In addition, through its internal taxation, it collects the necessary funds to finance its health sector.

Health funds are distributed from the regions to the LHA on the basis of capitation agreements.

At the beginning of the year, each LHA allocates a share of its budget for hospital activity: hospital care can be provided by independent public healthcare organisations (e.g. Hospitals, University Hospitals, Public Scientific Institutes of Hospitalization and Care (Italian abbreviation IRCCS), accredited private hospitals or directly public hospitals managed by the LHA.

Considering public providers - Public Hospital Trusts - they are independent public healthcare organisations controlled by a General Manager appointed by the region.

These are distinguished from the LHA with which they contract the volume and type of hospitalizations.

On the contrary, LHA hospitals are given a more limited autonomy, because they are managed directly by the LHA. University Hospitals and IRCCS (Institutes of Care and Research) are for the most part (public and private) educational facilities or hospitals that carry out research activities, for which they receive extra public funds for their part of research.

With these categories of suppliers (together with the accredited private actor, not taken into account in this research by virtue of its different legal nature), the buyer (LHA) stipulates a supply agreement, through which he contracts the number and type of health services as well as the constraints (global ceiling, tariff ceilings and cuts) in case of excess production.

The benefits, in case of hospitalization, are paid according to a DRG scheme, while the outpatient benefits are reimbursed according to a regional service tariff.

The internal organization of hospitals provides for a different nature of the production units, there is in fact a subdivision into simple operating units, complex operating units, departmental programs and intercompany operating units.

The difference between these is dictated by several factors, by the different nature of labour law, by the complexity of the activities carried out internally, by the size in terms of personnel belonging to the unit and by the fact that some units are developing on several structures at the municipal level to ensure high number and quality of care.