Evolution and implementation of the Italian health service reform of 1978.

The study seeks to answer two questions: Why and how was a national health service introduced in Italy in 1978. How, and how well, has the service worked. First proposals were made to improve public hygiene and access to health care in Italy in 1945. However, only in the 1970s was there political support for full reform. The principles of the national health service - full population cover, public funding, comprehensive services, local control - were agreed by most political parties; but there were also differences between parties over important issues. Parliament approved the law during an exceptional period in 1978 when the Christian Democrat party depended on the Communist party to sustain their government. The Servizio Sanitario Nazionale (SSN) has been implemented through the 19 regions and 2 autonomous provinces. 673 Unita Sanitarie Locale (local health units) provide the organisational structures for local management, with a wide range of services including general practice and hospital care, hygiene and prevention, occupational health and veterinary care. Terms of service are uniform across the country and negotiated nationally. About 15% of inpatient care, and about 30% of ambulatory care, is contracted to non-SSN salaried physicians. Public services in Italy are usually believed to be inferior to private services, to be excessively bureaucratic and of poor quality. Some evidence supports these perceptions, more commonly in the south than in cental or northern regions. Several features of the SSN, such as national planning, prevention and occupational health, and public participation, have not developed as intended in the reform. Neverthless, the SSN has also achieved several major objectives - a public health service available to all, an acceptable mix of public and private-contractual provision, public representation through regions and communes, and national financial control. On balance, the Italian health reform of 1978 has been a success