The context for supply and demand of public online services in Italy

Italy, officially referred to as Italian Republic, is a parliamentary republic. The country consists of 20 Regions, 105 Provinces and 8,100 Municipalities. The Italian state is undergoing a profound transformation process towards a Federalist structure, which has transferred exclusive legislative and executive powers to the Regions in several fields, including healthcare, environment, education and training, local security, and others. This process has resulted in increased conflict between local and national administrations, as Regions and Ministries struggle to define the new boundaries in the shifting balance of power.

Regional Authorities are central players in the evolution of the Italian government structure toward a federal form. Collaboration among Public Administrations has been identified as a key success factor of the government initiative for Italian eGovernment. In fact Regions have the responsibility to develop telecommunication infrastructure and services to enable the interoperability of the local administrations.

Key figures about Italy[1]

	Italy	Ø EU15	Ø EU25
Old age dependency ratio	28.9	25.5	24.5
Population density	192.2	119.8	116.3
GDP per head	104.7	108.6	100.0
GDP Growth- 5 year average	1.35%	1.85%	1.92%
Unemployment rate	8.0%	8.1%	9.0%
Inequality index	29	30	29

Local Administrations are the main interface of the Government to citizens and, as a consequence, the main providers of e-government services. They represent the front-office component in the eGovernment model[2].

Italy is a densely populated country, with a population density index considerably above the European average. Data from the Italian National Statistical Service[3] show that in 2003 there were 57,321,070 Italian residents and another 1,990,070 foreign residents that mainly came from Albania, Morocco and Romania.

Major parts of Italy's economic base are in good health, and GDP per head is above the EU25 average. In recent years, however, the country has experienced sluggish growth. Moreover, there are vast disparities among its regions; a huge gap exists between the economic potential of the north-centre and all other regions of the country, with the southern regions being the weaker ones. Unemployment in the country has remained stable during the past few years at 8%, which is the average level of unemployment for all European countries.

Information Society indicators[4]

	Italy	Ø EU15	Ø EU25
Households with Internet access	34%	45%	42%
Broadband penetration	6.1%	7.6%	6.5%
Price for Internet use basket	52.59	49.57	48.35
ICT expenditure as percentage of GDP	3.2%	3.2%	2.6%
Digital Divide Index	39	53	50.1

Italy's performance on the UN Telecom Index[5]

Internet penetration in Italian households is somewhat lower than in the rest of EU countries, and what is more, broadband penetration is still limited, partly due to high prices. Nevertheless, a recent study[6] presented on the Public Administration Forum revealed that during the past five years there has been a steady increase in the number of Internet users; in effect, the percentage of Italians online has doubled since 2000. More importantly, Italians do not limit their use of the Internet to the workplace; on the contrary, the vast majority connects to the WWW either from their home, or from both their home and workplace.

eHealth in Italy

The main access point for eHealth in Italy is part of the official government portal Italia.gov.it. This has a dedicated section on health, "Vivere in Salute", that can be regarded as the most widely known eHealth gateway for citizens in Italy. It provides access to information and services on general health issues under eight thematic areas. One of the most comprehensive areas is referral to a doctor, which also offers users the opportunity to get in touch with:

• the Local Health Authority (Azienda Sanitaria Locale-ASL) through links to the Health Ministry and to Regional portals that help find ASL;
• health services provided by family doctors;

• services provided in case of emergency and access channels to them;

• services provided in each Italian region, featuring links to Regional Health Portals;

• regions and municipalities that provide the opportunity to book health services online (at the moment, this option is available only in the case of one Region, Lazio).

The portal also provides information about healthcare for tourists and Italian citizens living abroad, and features links to regions that provide downloadable forms for request of health assistance abroad. Other areas of interest include vaccination, healthy diet, disease prevention and treatment, recommendation on the use of drugs, relevant health institutions for a given condition, and help on how to quit smoking.

Key figures about the Italian Health System [7]

	Italy	Ø EU15	Ø EU25
Percentage satisfied with own health	81.3%	82.5%	79.8%
Prevalence of long-term illness	12.0%	13.8%	20.0%
Doctors per 100,000 inhabitants	437	233	251
Health expenditure as percentage of GDP	6.4%	7.4%	7.3%

Regarding online services that are oriented towards providing information on health, both the government portal Italia.gov.it and the Regional Health Portals provide health information online. The Centre for Prevention and Control of Diseases, set up by the Health Ministry (Law 138, 2004), is another information source in Italy. The Centre is a network of competencies involving a number of Italian institutions working in the field. Its responsibilities are risk analysis, coordination with regions and diffusion of information. One can find information about the following topics: contagious and infectious diseases, promotion of healthy life style, vaccination, environment and health, accident prevention, and bio terrorism.

Apart from web-based information services and email contact, a call centre that gives advice to health operators as well as to citizens is available when dialling 15000. In addition, the website of the Health Ministry contains a section dedicated to health campaigns dealing with issues such as: food and diet, vaccinations for children, cardiovascular risks, smoking, alcohol, and AIDS. Services include applications for calculation of the individual risk score for heart disease, and links to the Institute For Health Research (Istituto Superiore della Sanità).

Citizens could find online information about health services on the regions' websites (21 in total). As mentioned before, in Italy, regions are responsible for the provision of heath services to citizens, thus, the content of these websites differs from region to region. For instance, regions that are well advanced in eGovernment include Emilia Romagna, Lombardy and Tuscany. Their websites provide wide and in-depth online information about available health services. In Emilia Romagna, an advanced Regional Health Portal called SALUTER provides information about prevention and healthcare, and about the organisation and provision of public health services. The Regional Health Portal from Tuscany also features a list of all family doctors including their office hours and services provided. On the other hand, an example of a region that is much less developed regarding the online availability of health information is Calabria. Its website contains very little information on health services, apart from the possibility to download the regional healthcare plan for the period 2004-2006. In summary, all Italian regions provide some information about health services on their websites, but the degree of interaction, the quality and quantity of information differ between them. Moreover, user awareness of the services is variable. It seems that regions with more developed eGovernment have also succeeded in reaching a high degree of visibility of healthcare services on the web.

Furthermore, since health service provision is organised at the regional level, as a consequence, administrative transactions are carried out at the same level as well. A list of health-related administrative transactions can be found in the Italia.gov.it portal. The list includes 13 administrative transactions that citizens can perform online, almost all of which are forms for online applications, such as change of the family doctor, request for health assistance in another EU country, etc.

Italian pharmacies have a dynamic presence on the Internet. First of all, there is a joint website ( www.farmacie.it ) with a search function for pharmacies in the user's region, and with information and news on health, but it does not provide the opportunity to purchase medications online. In addition, a number of traditional pharmacies have an online presence, either providing an online sales channel, or advertising their pharmacy. Lastly, online-only pharmacies do exist. Pharmacy websites only offer online purchase of cosmetics, baby care and natural products since in Italy, the law (122 T.U.L.S. of 1934) stipulates that, in the national territory, drugs should only be obtained from authorised pharmacies, and upon presentation of the original medical prescription when necessary. Moreover, the purchase of drugs from abroad that have not been approved in Italy is illegal, thus, no Italian online pharmacies sell products that have not been registered in Italy. Nevertheless, the press and pharmacy associations in Italy acknowledge the fact that there is a lack of legislative framework for the sale of medicines online, both at a national and at a European level[8].

General Practitioners with Websites[9]

With regards to the websites provided by doctors and clinics, the services provided by family doctors and general practitioners are known and classified as LEA (Livelli essenziali di assistenza, meaning basic assistance services). These services are provided directly by the Local Health Authority (ASL) or via general practitioners. Family doctors/general practitioners do not have websites, nor do they offer online interaction tools for their patients, but information about the doctors' services is in some cases provided by the ASL. In Tuscany and Lazio, for example, regional government portals contain lists of general practitioners as well as specialists. Specialists are also represented online through their associations. For example, ANMCO, the non-profit professional medical Cardiologists' association of the Italian National Health Service, has its own website at www.anmco.it.

Services for online second opinion are available only on commercial websites that provide healthcare related information in a popularised way, where people can write and ask for the opinion of a specialist. Another important case is Salute e Medicina Internet ( www.doctor33.it ) where citizens can obtain a second opinion about the diagnosis given by their doctor. Practitioners and specialists have the opportunity to contribute to the website after a registration procedure whereby they need to provide the website with a copy of their certificate of the Order of Doctors. Once registered, they can access incoming requests for second opinions, and send replies to the questions in their field of expertise. Replies will be made available online.

Telephone consultation with one's own GP/family doctor depends on whether GPs want to offer telephone consultation with patients or not. Some doctors are available for telephone conversations during certain hours of the day, and no general rule applies. Outside of office hours, there is a public service "Guardia medica" (medical guard), accessible through the same phone number (118) from all parts of the country. After receiving the telephone request and some information about the patient, a doctor may be sent to the patient's domicile. In addition, other telephone services are provided for emergencies such as the request of an ambulance, the request of advice/help to the Poison Centre (Centro Veleni).

One cannot find a national political framework to encourage the provision and usage of eHealth services because these kinds of policies and initiatives are under the responsibility of the regions. Furthermore, although they are funded by the Central Government (Health Ministry), health services in Italy are managed by regional governments, and healthcare services are directly delivered by the regions. As a consequence, the picture may be very different depending on the region and the local administration. As far as telephone consultation is concerned, it can be stated that, generally speaking, consultation by telephone or e-mail is not in any way encouraged in Italy, and, there is no specific legal framework either. Besides, the majority of family doctors are not available for telephone consultation. By and large, telephone consultation is limited to some urgent intervention in order to assess what type of immediate treatment is needed, as in the case of the poison centre hotline.

User orientation in eHealth services

The Italians' perception of the national healthcare system is not at all positive; in fact they are one of the most dissatisfied people among citizens of the old EU member states. This stresses the need to create better and more user oriented services for Italian citizens.

Satisfaction with National Healthcare System[10]

However, an evaluation of user orientation at a national level is not easily possible since, although it is funded by the Central Government (specifically by the Health Ministry), the National Health Service is managed by regional governments; therefore the regional level is of most importance for the actual delivery of health care services. This means that the level and quality of online health information services differ a lot between regions, in spite of some common features determined by the national health system, and policy-making at national level. As a consequence, user orientation of eHealth can only be analysed at regional and local level.

Nevertheless, an assessment of the eHealth services available in Italian regions and municipalities reveals an interesting point: Where eGovernment is already at an advanced stage, eHealth services are available and tend to be well visible and accessible. On the other hand, where eGovernment is still at a starting point, eHealth services are not widely developed. Thus, a slow development of eGovernment is surely one of the most important barriers to the development of supply and demand for eHealth.

Internet Use for Searching Health Information[11]

From a positive viewpoint, an important driving force towards the uptake of eHealth services by Italian citizens is the recent initiative to simplify administrative procedures for providing and acquiring health services in the public domain. The Italian public health system is known as being complicated, and characterised by long waiting lists. Application procedures are complex, and often include a number of application forms. So the use of the Internet is expected to help streamline these procedures.

eUser - the Project

The eUser study is funded by the European Commission's IST (Information Society Technology) programme. eUser is a major research and support project which has set out to provide solid evidence as to users' real needs regarding eGovernment, eHealth and eLearning offers, as well as providing data about their attitudes and the uptake levels of current public online services. The project supports the IST programme to achieve its key objectives of putting the user and his/her needs at the centre of IST developments. It provides empirical information on key public eServices domains -eGovernment, eHealth, eLearning - identified as priorities by the European Council, and assesses the demand/supply match in these fields.

The eUser Approach

To achieve its objectives, eUser addresses both generic user-related issues and domain-specific topics, and develops a globally accessible repository of evidence-based knowledge, methods and best practice examples. It pursues an extensive programme of active knowledge translation, transfer and dissemination supported by sophisticated online knowledge dissemination tools. The knowledge base will consolidate both existing knowledge and approaches, and novel data generated by the project through representative population surveys (demand side) in old and new Member States, and through comparative analyses of readiness to address user aspects of public eServices in each Member State (supply side).

The project is designed in two phases. Phase I - the preparatory phase - has developed a conceptual framework that systematically identifies and cross-references user issues and service characteristics in relation to online public services. An EU-wide population survey regarding the needs, experiences and requirements of both current and potential users of online public services has been carried out in early 2005. Concerning the supply side, information from national public sector environments has been collected, about the degree to which the European public sector pays sufficient attention to user-orientation of online services. Good practice examples regarding user-appropriate online public service provisions are being identified and described.

All these results build the basis and provide content for the eUser interactive online knowledge base and support service which is being set up as an online observatory on user issues. This constitutes the basis for active support services on user-centred topics which are being made available inside and outside the IST programme.

eUser Country Briefs

This document has been prepared by FORTH based on information provided by a National Correspondent (Rosanna Lifonti, Databank Consulting) as well as secondary data sources such as Eurostat and other Commission Services.

25 eUser eHealth Country Briefs are available in a common format, one for each member of the enlarged European Union. You can access and download these documents in PDF format (for free) from our website.

Notes About the Data Sources Used in this Document