State of health and inequalities among Italian regions from 2000 to 2021: a systematic analysis based on the Global Burden of Disease Study 2021.

Background: Over the past two decades, the Italian National Health Service has been gradually decentralised, with Italy's 21 regional governments now responsible for managing their health services. This change, coupled with austerity measures and a steadily ageing population, has adversely affected universal health coverage and equity, exacerbating inequalities and regional disparities. This study aimed to analyse time trends and subnational differences in the burden of disease from 2000 to 2019, and from 2019 to 2021 to capture the effects of the COVID-19 pandemic.

Methods: This study uses estimates for Italy from the Global Burden of Diseases, Injuries, and Risk Factors Study 2021. We analyse trends and geographical differences in disease burden from 2000 to 2021. Metrics include life expectancy, health-adjusted life expectancy (HALE), years lived with disability (YLDs), years of life lost (YLLs), and disability-adjusted life-years (DALYs) observed at national, macroregional, and subnational levels. Percent changes in rates, with both all-age and age-standardised rates, and 95% uncertainty intervals (95% UIs) are reported.

Findings: Life expectancy at birth in Italy increased from 79·6 years in 2000 to 83·4 years in 2019, dropped to 82·2 years in 2020 due to COVID-19, and recovered slightly to 82·7 years in 2021. HALE was 70·9 years (95% UI 67·4-73·8) in 2021. Substantial regional disparities were observed: in general, despite higher YLD rates, northern regions had better health outcomes, with higher life expectancy and HALE and lower YLL rates compared with southern regions. Overall, the top causes of YLDs were low back pain (1556·5 [1098·5-2080·2]), falls (926·2 [638·8-1253·8]), and headache disorders (858·0 [173·7-1808·2]). Anxiety and depressive disorders both had substantial increases in the period from 2019 to 2021 (19·8% and 17·3%, respectively). YLDs for Alzheimer's disease and diabetes increased substantially from 2000 to 2019 and 2019 to 2021 (70·6% and 3·0% for Alzheimer's disease and 46·8% and 7·9%, respectively for each timepoint). YLL rates declined for ischaemic heart disease from 2000 (-29·9% in 2019), but increased for Alzheimer's disease and other dementias (54·5%). DALY rates decreased overall from 2000 to 2019, but rose again in 2021 due to the COVID-19 pandemic.

Interpretation: The study highlights considerable regional disparities in Italy's health outcomes, driven by demography, heterogeneous health service quality, and economic inequalities. Addressing the increasing burden of Alzheimer's disease, diabetes, and mental health disorders, as well as regional disparities, requires strengthened preventive measures, equitable health service access, and socioeconomic policies, both at the national and regional levels.

Funding: Bill & Melinda Gates Foundation.