Italy, Portugal, and Spain are all countries in Southern Europe with long histories of providing universal healthcare to their citizens. All three countries have public healthcare systems based on the principles of universal, free and equitable healthcare for all eligible people in their respective countries that are funded through taxation, and all three countries offer a high standard of care.

However, each country has its own unique approach to healthcare, combining elements of public and private provision. By examining their similarities, differences, and notable features, we can gain a better understanding of how these countries prioritise healthcare for their citizens.

Italy: a universal, decentralised and low cost system

Italy's healthcare system is one of the oldest and most well-established in the world. It was first introduced in 1883, and it has been continuously updated and improved ever since. Italy's current form of universal healthcare was first legislated in 1978 and called the Servizio Sanitario Nazionale (SSN).

Predominantly public and universal in nature, the SSN is highly ranked internationally. The World Health Organization (WHO) ranks it second after the French system. The Organisation for Economic Co-operation and Development (OECD) ranks Italy's life expectancy among the highest with the lowest healthcare spending among the countries it ranks. Italy boasts a high life expectancy and low rates of infant mortality.

It provides comprehensive coverage to all Italian residents, regardless of their socio-economic status.

All legal foreign residents and citizens are automatically covered by a comprehensive range of healthcare services. All services are free and Italy's universal healthcare system is based on the foundation of solidarity, health and human dignity.  Undocumented immigrants are also eligible for basic healthcare as of 1998.

Costs of healthcare

Primary healthcare and essential hospital care are free, which includes doctor consultations.

However, specialist care including certain diagnostic procedures and prescription medications requires a copayment from the patient. This amount is not usually high and depends on the treatment required and the region.

Exemptions to copayments apply to pregnant women, the elderly, children and people below a certain income threshold.

Funding of healthcare

The Italian healthcare system is funded through a combination of national and regional taxes, and it is administered by the Ministry of Health. As a decentralised system, responsibility for healthcare delivery is delegated to the 21 Italian regions. The Ministry of Health allocates national funding to the various regions based on calculations which take into account factors such as previous expenditures, etc.

Healthcare management

Italy has a decentralised approach, with regional governments managing and delivering healthcare services. The country is known for its strong emphasis on primary care and preventive medicine.

The administration of the system is primarily regional with the general objectives of the Healthcare Act enforced by the national government. Each of the regions is independent and is responsible for setting its goals and priorities. Therefore, healthcare may vary in regions in terms of quality. Regions also generate independent income which creates interregional financing differences.

There are 19 regions and two self-governing provinces that utilize 100 local health units to deliver hospital, primary care, outpatient, public health and social care healthcare services. Each of the local health units has a general manager that is appointed by the governor of that respective region.

Private health insurance

The SSN does not allow people to opt out of national health insurance in favour of private health insurance. However, individuals can buy private health insurance. Around 10% of people have voluntary health insurance to cover services excluded from the SSN, private hospital benefits and access to a greater choice of healthcare services.

Private insurance can either be corporate where the employer covers the individual and their family or noncorporate where people pay for their own private health coverage.

Portugal: a mixed system, with both public and private providers

Portugal's national health insurance or Servico Nacional de Saude (SNS) is also based on universal coverage. It was created in 1979 and is administered by the Ministry of Health. It is defined as universal, national and free. It is available to all citizens and legal residents. Eligible people have to register with their local council to access medical services.

The SNS provides a comprehensive list of medical services. The SNS is administered by local and regional health clinics and hospitals which belong to the public health network. The Portuguese healthcare system is administered by the Ministry of Health, and it is divided into three levels: primary care, secondary care, and tertiary care. Primary care is provided by general practitioners (GPs) and community health centers. Secondary care is provided by hospitals and specialized clinics. Tertiary care is provided by university hospitals and research centers.

Access to the SNS is free to people over 65 years and under 18 years, as well as dependent family members. All other eligible people have access to high-quality subsidised healthcare with a low copayment. 

It is funded largely through general taxes and contributions made by employees into the social security system, with additional revenue coming from user charges. Patients are required to make a copayment towards their healthcare which is usually around €5.

Exclusions listed on the national health insurance system are dental and vision care but for certain groups of people such as low-income, these are still covered.

Some people take out private health insurance to supplement their coverage from the public health care system. Approximately one in five residents have private health insurance to cover excluded services, quicker access to specialists, etc.

According to the 2023 Health Care Index by Numbeo, Portugal's healthcare system ranks 25th. The World Index of Healthcare Innovation 2022 ranked Portugal at number 22 according to factors such as quality, healthcare choices available, financial sustainability, and science & technology.

The average life expectancy has increased to 82.47 years in 2022 from the previous year which is a testament to an efficient and effective public healthcare system.

Spain: funded through a combination of national and regional taxes

Spains's public healthcare system is also based on the principles of universal, free and equal access for all eligible citizens and residents. It is called the Sistema Nacional de Salud (SNS) and it is a two-tiered organisation. One level is national whilst the other is the regional level.

1. On a regional level, there are 17 regional autonomous healthcare departments. Each of them is responsible for the organisation, administration and delivery of healthcare in their region.
2. At the national level the SNS Interterritorial Council, which is comprised of the Minister of Health and all 17 regional ministers of health, coordinate the SNS by planning and regulating laws and overseeing the national health budget.

The SNS has been operational since 1986 when the General Health Law was promulgated.

Spain operates one of the best healthcare systems globally which translates to an exceptional standard of living for Spanish people. The overall life expectancy is 83.5 years old. It ranked 7th globally in 2009 by the World Health Organization. Additionally, it ranked sixth in the EU for the best doctor-to-patient ratio which stands at 4:1000 people.
The 2019 Bloomberg Healthiest Country Index places Spain comfortably on the top.

Spain also ranked eighth of 89 countries ranked in the 2021 Health Care Index.

Free healthcare is available for those living and working in Spain, children, students below the age of 26 and pregnant people. Other eligibility criteria for free healthcare are: recently divorced/separated people from a partner who was registered for social security, pensioners, recipients of state benefits and nationals from the EU/EFTA holding a European Health Insurance Card (EHIC).

Undocumented migrants are required to pay 40% of prescribed medicines. 

All basic medical services are free but surgeries, hospital stays and some diagnostic procedures require a small copayment. Any specialised medical care may be more expensive.

Approximately 70% of funding is derived from public taxes which make up about 11% of the GDP. Employed residents also contribute towards the social security fund. Funds are then allocated to each region through a complex system to ensure there are no regional disparities for essential services.

Many Spanish residents also purchase private health insurance to supplement public healthcare. 

Conclusion

The healthcare systems of Italy, Portugal, and Spain are all excellent, and they all offer a high standard of care. Each country has its own strengths and unique features, such as Italy's emphasis on primary care with a healthcare system that is decentralised and has a lot of government control, Portugal's comprehensive health centers with a decentralised system and more regional control, and Spain's specialization in certain medical areas, with a healthcare system that is affordable and easy to access.

Italy, Portugal, and Spain have made commendable efforts in developing healthcare systems that aim to provide universal coverage and quality care to their citizens. While challenges exist, these countries continue to evolve their healthcare systems to meet the changing needs of their populations.

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