Editorial - Epidemiological transition, crisis of the Italian health system: ethical and logical economic choices.

Forty years after its establishment, the Italian National Health Service (INHS), based on three foundational principles, universality, equality and equity, is one of the best in the world. Over the past 30 years, Italian healthcare spending has grown to 2011 and then declined steadily1. In 2016, Italian healthcare, both public and private, was around 8.9% of Gross Domestic Product (GDP), while Germany spends 11.1%, France 11.5% and Europe 9.9% (Figure 1)2. Although Italy invests less in health than these countries, the results, in terms of guarantee for the citizen and health, are excellent. This also occurred in what concerned life expectancy, at least for those who have been using the INHS for years3. The epidemiological transition and the increase in chronic non-communicable diseases (CNCD) imposed changes to make the INHS sustainable, modifying the interventions respect to the transition itself4. CNCDs, including obesity, cardiovascular disease, diabetes mellitus, neurodegenerative diseases, chronic respiratory diseases, cancer, are the most frequent causes of prolonged disability and death worldwide5. CNCDs are the most important cause of death, which increased worldwide, between 2000 to 2016, from 60.38% to 71.24%, respectively, and in Italy reached 91.4%6. In addition to a high mortality rate, CNCDs are also disabling, as evidenced by the years of life lost. In Europe, about 60% of the Disability Adjusted Life Year (DALY) related to CNCDs, is attributed to seven main risk factors: blood pressure (12.8%), smoking (12.3%), alcohol (10.1%), high cholesterol (8.7%), overweight (7.8%), reduced intake of fruits and vegetables (4.4%), and physical activity (3.5%). The DALY is equal to the sum of the years of life lost due to an untimely death and of those experienced in illness rather than health5. If on one side medical therapies, diet, drugs and surgery can reduce premature mortality and improve life expectancy, on the other it has observed an increase of prolonged disability, leading to serious socioeconomic burdens, also related to days off work7. In Italy, 2017 data showed that 24 million patients had at least one chronic disease, after 75 years more than 90% are affected. Currently, CNCDs healthcare expenditure is around 67 billion and, in 2050, over 75% of public health resources will be destined to these diseases8. In the USA, health expenditure is disproportionate to the wealth and is about double ($ 10,224) of other economically comparable countries ($ 5,280). However, health expenditure in the USA and in comparable countries has gone down in recent years: in the USA from 7.2% in 2000-2005 to 3.6% in 2015-2017; in the other comparable countries from 5.6% in 2000-2005 to 2.5% in 2015-20179. In Italy, in 2016, the total health expenditure decreased and amounted to almost € 158 billion, divided as follows: 113 for public spending; 45 for private spending, variously distributed, of which almost 40 billion out-of-pocket spending. This amount represents the 23% of the expenditure and the acceptable threshold is 15%. If health spending with own resources exceeds 15%, social equity is no longer guaranteed10. In the USA, from 1970 to 2016, private healthcare expenditure increased from 3.9% to 8.8%, with a similar rate compared to other economically comparable countries11. In Italy, between 2010 and 2016, the per capita public health expenditure decreased (-8.8%). In Germany (+11.4%), in France (+ 6.2%) and in the Netherlands (+2.6%) health expenditure increased. While it decreased in Spain (-3.8%), Portugal (-14.4%) and Greece (-38.3%). In the meantime, the private health costs increased12. European Review for Medical and Pharmacological Sciences 2020; 24: 4616-4622