Q&A: State of health in Italy from 2000 to 2021

A new study published in The Lancet Public Health analyzed trends and geographical differences in disease burden across Italian regions from 2000 to 
2021. Study authors used several health metrics to understand how health outcomes differ at national, macro-regional, and subnational levels. We speak with Dr. Lorenzo Monasta, National Collaborator, Italian Global Burden of Disease Study Initiative.

This transcript has been lightly edited for clarity

Why was the research into the subnational burden of disease in Italy undertaken?

For the first time, with this 2021 round of the GBD, the GBD is releasing subnational estimates for Italy, which cover 19 regional and two autonomous provinces. We published the first paper on Italy in 2019, which was based on GBD 2017 estimates and could not count actually on subnational estimates. Regions in Italy present differences in terms of age structure, SDI [Socio-demographic Index], and quality and access to health services.

So for this reason, subnational estimates are invaluable for us to be able to assess differences and inequalities among regions and their epidemiological profiles.

What were the key findings of the research?

The study highlights considerable regional disparities, as expected, in Italy’s health outcomes, driven mainly by different population structures, heterogenous quality and access to health services, and economic inequalities also, which is something that we know—regions in the north are wealthier than regions in the south—and different, also, distribution of risk factors.

So, we have higher alcohol consumption in the north, for example, but higher BMI in the south, plus we are seeing increasing fatal burden of Alzheimer’s disease, increasing incidence of type 2 diabetes, increasing mental health disorders, especially anxiety, and significantly higher life expectancy in females, more than males.

Life expectancy is quite high in Italy, 82.65 years. And it increased three years in the last 20 years. But several considerations can be made, looking at the figure. Even if the life expectancy in males increased more than in females, 2.5 for females and four years for males, in 2021, it was still lower for males than for females in the year 2000. So, it’s still a significant gap.

How critical are Italy’s aging population and falling fertility rate in its future health care?

In Italy, the fertility rate has been below the replacement level of 2.1 since 1976. So, up until recent times, no significant action had been put in place to mitigate this trend, either on the side of fertility rate or on the side of healthy aging policies. Now, today, the actual fertility rate is 1.24, one of the lowest in the world.

The aging of the population reflects on our epidemiological profile. So, especially in some regions in the north, the burden due to comorbidities and noncommunicable diseases is high, affected by the cumulative effect of metabolic risk factors.

What regional disparities were uncovered, and what are the drivers behind them?

There are two main differences between regions of the north and center and regions of the south and islands. The first is related to older population structures, as I said, of the regions of the north, which translates into higher YLDs [years lived with disability] due to noncommunicable diseases and high rates of comorbidities. The second can be seen if we use age-standardized rates, we see a higher burden in the south and islands in the younger population due to higher exposure to behavioral and metabolic risk factors and lower access and quality of health services.

Almost three years’ difference we can see between the regions with the highest and the lowest life expectancy. This is also an important result. And since 2010, the increasing curve has flattened for both males and females. And this is also due to changes in the economy of the country, and the access and quality of health services.

And then we can see the impact of COVID on life expectancy, which was delayed in the regions of the south and islands with respect to the regions in the north and center.

These maps reflect what we previously mentioned about the different distribution of the fatal burden of disease. If we look at the crude burden, that is just the rates of years of life lost (YLLs), in the first figure we see how especially Liguria, Friuli-Venezia-Giulia, and Molise, suffer from having older populations, so region numbers 8, 7, and 15, which are more reddish.

And if we look at the age-standardized YLL rates— that means adjusting for differences in population structure—we see how, as mentioned before, regions in the south, especially Campania, which is number 16, Sicily, which is number 20, and Calabria, which is number 19, have higher burden in fatal age-adjusted rates.