Journal of ISSN: 2373-4310JNHFE

Nutritional Health & Food Engineering
Review Article
Volume 6 Issue 1 - 2017
Medical Benefits to Safeguard Coeliac Consumers and their Impact on the Gluten-Free Product Market: The Case of Italy
Gavina Manca*
DISEA-Lab of Commodity Science, Technology and Quality, University of Sassari, Italy
Received: October 28, 2016 | Published: January 02, 2017
*Corresponding author: Gavina Manca, University of Sassari, DiSEA-Lab. of Commodity Science, Technology and Quality, Via Muroni 25, 07100 Sassari, Italy. Tel: +39079229579; Email:
Citation: Manca G (2016) Medical Benefits to Safeguard Coeliac Consumers and their Impact on the Gluten-Free Product Market: The Case of Italy. J Nutr Health Food Eng 6(1): 00186. DOI: 10.15406/jnhfe.2017.06.00186

Abstract

In Italy coeliac suffers have the right to obtain free provision of gluten-free products against National Health Service prescription-coupons. The survey on the various ways the law is applied in the different Italian regions showed that these patients don’t enjoy uniform social security treatment through the country. Furthermore it was observed that the healthcare system has affected the gluten-free product market. On examining the prices of these foodstuffs, it was found that they were more costly than their standard counterparts (from 68 to 595%). Differences were also found between the prices of gluten-free products bought at different shopping venues (from 10 to 330%). In order to encourage competition between shopping venues and bring down the prices of gluten-free foodstuffs, it seems necessary to allow the large-scale retail trade to deliver gluten-free products against National Health Service prescription-coupons in all the Italian regions.

Keywords: Gluten-free products; Medical benefits; Italian market

Introduction

Coeliac disease is a chronic gastrointestinal disorder occurring in genetically susceptible individuals because of an immune response to gluten [1]. The major protein complex found in wheat, barley and rye [2]. It is believed that coeliac disease is the most common food intolerance in the Western population and it is considered to affect 0.3% to 2% of the population. The number of coeliac patients is unfortunately destined to increase annually because of the great variability of symptoms and signs by which coeliac disease is manifest, which often makes its diagnosis difficult, and as a result there are frequent cases of delayed diagnosis [3]. It is estimated that for every coeliac sufferer diagnosed, there are at least ten who are not aware of being affected [4].

In Italy, against the approximately 140,000 cases diagnosed each year there are actually 5,000 new diagnoses and 2,800 new coeliac sufferers, with an annual increase of about 10%. In 2012 148,662 individuals were positively diagnosed with coeliac disease in Italy, 12,862 more compared with the preceding year. The regions with the greatest number of coeliac sufferers were Lombardy, Lazio and Campania. Whereas Sardinia and Tuscany were among the regions where the greatest prevalence was recorded, with their 0.31% (Annual Coeliac Parliamentary Report 2012 Edition).

In order to give assistance to coeliac sufferers and their families and to raise the awareness of the political institutions to ensure the rights of coeliacs and their full implementation, independent non-profit organisations have arisen in different States of the world (e.g. the Association of European Coeliac Societies, AOECS). In some countries, thanks to the continuous dialogue between these associations and the institutions, it has been possible to obtain regulations relating to the characteristics, production and labelling of gluten-free products and a partial refund for the purchase of gluten-free products from the Health Services.

Since 1979 in Italy there has been the “Associazione Italiana Celiachia” (AIC), whose widespread activity led to the enactment of Law N° 123 of 4 July 2005, which approved the status of social disease for coeliac disease. Article 4 of the law recognises the right of coeliacs to obtain support from the Italian Health Service in terms of a free supply of gluten-free products.

Although they have respected the national law, the various Italian regions (in Italy there are 21 regions with their own statutes, powers and functions) have legislated in different ways, owing to their legislative autonomy. Hence coeliac patients in Italy do not enjoy uniform social security treatment throughout the country. For these reasons this study has involved a survey of the medical benefits offered by the Health Services in the different Italian regions, in order to identify the solutions some of them have adopted to provide more effective and satisfactory services for coeliac needs. Moreover, to assess the impact of the regulations on the gluten-free product market, the price differences of these products were evaluated compared with conventional foods but also in relation to the different retail channels. The case of Sardinia was investigated as regards this issue, an Italian region with the highest percentage of coeliac sufferers compared with the resident population.

Methods

In order to investigate the differences in social security regulations (i.e. healthcare) for coeliacs in the 21 Italian regions, the websites of the 21 Regional Offices of the Associazione Italiana Celiachia (AIC) and of the Italian Ministry of Health were explored and all the regional legislation in favour of coeliac patients studied. To evaluate the difference in prices of gluten-free products, a basket of products contained in the “Registro Nazionale degli Alimenti Destinati ad una Alimentazione Particolare”, chosen from those easily obtained at all retail venues and purchased almost daily by coeliacs (such as bread, pasta, biscuits, pizza, ice-cream and flour), were taken into consideration. Prices were surveyed at 13 retail venues located in North Sardinia: 5 large-scale retail stores, 3 specialist shops and 5 pharmacies. With the aim of widening the comparison, 5 on-line stores were also considered. These four retail categories were chosen to reflect the various shopping venues used to buy foodstuffs for daily use. For the price comparison between gluten-free products and the equivalent conventional foods the survey was carried out at 5 large-scale retail chains as both categories of products are readily available at these stores. To evaluate the significance of the price differences of products sold at the different shopping venues the one-way ANOVA test was used to compare mean values. When a significant p-value was found, means were separated using the Bonferroni post hoc test at a confidence level of 95%. All the statistical analyses were performed with the software package SPSS 14.0 (SPSS Inc., Chicago, Il, USA).

Results

Free provision of gluten-free products in the various Italian regions

In Italy free provision of gluten-free products is obtained against “vouchers” or “prescription-coupons” issued by the Local Health Authorities (public boards dealing with the financial organisation and management of health services) following specialist diagnosis of the disease. This “voucher” enables the coeliac sufferer to obtain the foods at shopping venues under contract with the Local Health Authorities. Monthly expenditure limits for dispensing gluten-free products were established by Decreto Ministeriale (DM) of 4 May 2006 and these are shown in Table 1. This upper limit is divided into the requirements of people of different ages and sex, based on their physical condition and their various dietary needs that affect their different requirements of calories and carbohydrates. From our analysis of the regional regulations, differences arose in the way the various Local Health Authorities dispense gluten-free products. In effect, some Italian regions, such as Friuli Venezia Giulia [5], Trentino Alto Adige [6], Veneto [7], Piedmont [8], Aosta Valley [9] and Tuscany [10], have established different age-groups and monthly expenditure limits that are approximately 10-99% higher than those established by the DM of 4 May 2006. Moreover, all these regions, with the single exception of Tuscany, make no discrimination between the sexes (Table 2).

Age-Group

M ()

F ()

6 months – 1 year

45

45

Up to 3.5 years

62

62

Up to 10 years

94

94

Adults

140

99

Table 1: Upper Limits of Monthly Expenditure Established by Italian National Health Service [17].

 

DM 4 May 2006

Friuli-Venezia Giulia

Trentino

Veneto

Piedmon

 

Tuscany

Aosta Valley

Age-group

M

F

M and F

M and F

M and F

M and F

M

F

M and F

0 months-3 years

67.97

6-9 months

142.23

6 months-1 year

45

45

50

50

54

6 months-3 years

60

60

9-12 months

142.23

1-3 years

70

70

142.23

1-3.5 years

74.4

Up to 3.5 years

62

62

3-6 years

100

100

142.23

3-8 years

123.95

3-10 years

90

90

3.5-10 years

112.8

6-10 years

105

105

6-12 years

142.23

8-15 years

144.61

Up to 10 years

94

94

> 10 years

135

140

144

125

110

12-18 years

142.23

> 15 years

180.76

Adulthood

140

99

142.23

Table 2: Monthly Expenditure limits (€) in Italian Regions That Have Adopted Different Ways of Dispensing from Those Established by DM 4 May 2006 [17].
M=Male; F=Female

The Aosta Valley is a special case, where the same monthly expenditure limit is envisaged for all age-groups (Table 2) but product categories have been introduced with maximum quantities able to be supplied that are differentiated according to the various age-groups (Table 3). This system was also present in other regions, such as Sardinia, but had been abandoned due to the extra work for sales staff and the difficulty of achieving the correct quantity to be supplied for products that cannot be sold by weight.

Age-Group

Type of Food

Maximum Amount (g)

6-9 months

Small pasta

1000

Biscuits

600

9-12 months

Small pasta/semolina

2000

Biscuits/granulate

600

1-3 years

Pasta/flour/bread/crisp read/crackers/grissini

4000

Biscuits/cakes

1000

3-6 years

Pasta/ flour/bread/ crisp bread/crackers/grissini

5000

Biscuits/cakes

1500

6-12 years

Pasta/ flour/bread/crisp bread/crackers/grissini

9000

Biscuits/cakes

1500

12-18 years

Pasta/flour/bread/crispbread/crackers/grissini

11000

Biscuits/cakes

2000

>18 years

No distinction

13500

Table 3: Maximum Monthly Provision of Foods per Age-Group envisaged by Aosta Valley Region (DGR 2791/22009 and DGR 160/2011) [9].

The monthly prescription-coupon usually has to be spent at a single store; some regions make an exception, such as Liguria [11], Friuli Venezia Giulia [5], Emilia Romagna [12], Umbria [13], Lazio [14], Marche [15], Piedmont [16] & Calabria [17], where the monthly contribution is broken down into several prescription-coupons (Table 4), so that patients have the chance to obtain the products throughout the month, and at various contracted stores. The electronic instrument for managing prescription-coupons proves not to be very popular, as only a few provinces of Lombardy Region have had their Local Health Authorities start up the WEBCARE service. In this case the Local Health Authority Pharmaceutical Service is linked in an electronic network with all contracted trade outlets on the territory where users can therefore apply direct to obtain products. Another example is the Caserta Local Health Authority, in Campania Region, where the users in question have had an electronic card to use in replacement of the paper vouchers since 1st February 2010.

 

Liguria

Friuli Venezia Giulia

Emilia Romagna and Umbria

Lazio

Marche

Piedmont

Calabria

Age-group

M

F

M and F

M

F

M

F

M

F

M and F

M

F

6 months-1 year

3 (value 15.00)

3 (value 15.00)

 

4 (value 11.25)

4 (value 11.25)

2 (value 22.50)

2 (value 22.50)

3 (value 15.00)

3 (value 15.00)

4 (value 13.50)

4 (value 11.25)

4 (value 11.25)

1-3 years

 

 

2 (value 25.00)

 

 

 

 

 

 

 

 

 

1-3.5 years

 

 

 

 

 

 

 

 

 

4 (value 18.60

 

 

Up to 3.5 years

2 (value 20.00) and 1 (value 22.00)

2 (value 20.00) and 1 (value 22.00)

 

4 (value 15.50)

4 (value 15.50)

2 (value 31.00)

2 (value 31.00)

3 (value 20.67)

3 (value 20.67)

 

4 (value 12.50)

4 (value 12.50)

From 3 to 6 years

 

 

4 (value 25.00)

 

 

 

 

 

 

 

 

 

3.5-10 years

 

 

 

 

 

 

 

 

 

4 (value 28.20)

 

 

6-10 years

 

 

3 (value 25.00 and 1 (value 30.00)

 

 

 

 

 

 

 

 

 

Up to 10 years

4 (value 20.00) and 1 (value 14.00)

4 (value 20.00) and 1 (value 14.00)

 

4 (value 23.50)

4 (value 23.50)

2 (value 47.00)

2 (value 47.00)

3 (value 31.33)

3 (value 31.33)

 

4 (value 23.50)

4 (value 23.50)

> 10 years

 

 

4 (value 25.00) and 1 (value 35.00)

 

 

 

 

 

 

4 (value 36.00)

4 (value 35.00)

4 (value 24.75)

Adulthood

7 (value 20.00)

4 (value 20,00) and 1 (value 19.00)

 

4 (value 35.00)

4 (value 24.75)

2 (value 70.00)

2 (value 49.50)

3 (value 46.67)

3 (value 33.33)

 

 

 

Table 4: Number and Value of Monthly Prescription-Coupons (€) in Liguria, Friuli Venezia Giulia, Emilia Romagna, Umbria and Lazio.
M=male F=female.

Sales channels for gluten-free products

In Italy National Health Service-dispensed gluten-free products must meet specific safety requirements and must therefore be registered in the Registro Nazionale dei prodotti destinati a un’alimentazione particolare (Ministry of Health website) set up by the Italian Ministry of Health with DM of 8 June 2001. These products cannot be sold by weight but only as pre-packed goods. From 1982 onwards gluten-free products could be dispensed free of charge in exchange for vouchers by pharmacies only. Since 2005, however, prescription-coupons can be used at different stores from pharmacies, such as large-scale retail outlets, specialist shops (a market that carries foods specifically designed for special dietary needs such as diabetic, organic, gluten-free and vegan foods) and parapharmacies (specific sales points where it is possible to purchase over-the-counter pharmaceutical products, self-medication products, products for children and all those products usually sold without a prescription at pharmacies). With the exception of pharmacies open to the public, all other trade outlets that wish to dispense these specific foods on behalf of the National Health Service must make an explicit application for authorisation to the Local Health Authority competent for the territory and accept the following conditions:

  1. Guarantee a suitable assortment of gluten-free products from those included in the National Foodstuffs Register, which should represent roughly 80% of the whole assortment;
  2. Dispense the said products in the way and at the reimbursement rates defined in national regulations, as well as following further regulations defined by the health authority competent for the territory;
  3. Guarantee the fulfillment of all requirements in terms of information for consumers expressly required by the Local Health Authority, making the National Foodstuffs Register’s latest update available for consultation.
  4. For the medium and large sales facilities it is also required that a specific information point be set up, to be located along the customers’ route.

At the present moment in all Italian regions the large-scale retail trade is authorized to dispense gluten-free products, but not in all regions do Local Health Authorities have contracts with this retail channel. The region of Tuscany was the first to open its doors to the large-scale retail trade, while in other regions this was permitted from 2007 onwards and yet others from 2013 only. Thus, at the moment almost all the Local Health Authorities of the Italian regions now have contracts with the large-scale retail trade, with the exclusion only of Basilicata, Campania, Molise, Sardinia, Sicily and Aosta Valley (Table 5). The opening up of sales of these foodstuffs through the large-scale retail trade channel is a great breakthrough for coeliacs as it provides a service with a double value – both practical and psychological: on the one hand the convenience of shopping for the whole family and on the other the “demedicalisation” of coeliac disease. Moreover, the greater competition that has been created has enabled the excessive costs of gluten-free products to be brought down.

Region

Large-Scale Retail Trade

Pharmacies

Specialist Shops

Parapharmacies

Abruzzo

X

X

X

X

Alto Adige

X

X

X

Basilicata

X

X

Calabria

X

X

X

X

Campania

X

X

X

Emilia Romagna

X

X

X

X

Friuli Venezia Giulia

X

X

X

X

Lazio

X

X

X

X

Liguria

X

X

X

X

Lombardy

X

X

X

X

Marche

X

X

X

X

Molise

X

X

Piedmont

X

X

X

X

Apulia

X

X

X

Sardinia

X

X

Sicily

X

X

X

Tuscany

X

X

X

X

Trentino

X

X

X

Umbria

X

X

X

X

Aosta Valley

X

Veneto

X

X

X

X

Table 5: Distribution Channels Authorised to Dispense Gluten-Free Products Under Contract in the Various Italian Regions.

Specialist shops are also quite popular; only in Aosta Valley is this channel not authorized to accept prescription-coupons. Currently the least-used channel is the parapharmacies: only 14 regions out of 21 envisage a contract with these trade outlets.

Comparison between gluten-free prices at various sardinian sales outlets.

With the purpose of evaluating whether the Italian contracting system has an effect on the prices of products in the various sales channels, a survey was carried out in the Sardinian region involving a basket of six products contained in the Foodstuffs Register (bread, pasta, biscuits, pizza, ice-cream and flour), chosen from among those most sold and available at all shopping venues and which consumers buy in everyday life. The prices of the basket of gluten-free products considered were checked at 5 large-scale retail stores, 3 specialist shops and 5 pharmacies. The survey was also extended to 5 on-line shops. For all products the prices at large-scale retail stores were usually lower than those found at other shopping venues, where the increase ranged between 10 and 86% with peaks of 330% for flour, which proved to be the product with the greatest price difference (Figure 1).

Figure 1: Percentage Price Difference between Gluten-Free Foods Found at Large-Scale Retail Stores Compared Specialist Shops and Pharmacies.

As regards on-line products, it was observed for ice-cream only that this sales channel turned out to be less expensive than the large-scale retail stores (-3%), while for the other products percentage increases were observed ranging from 17 to 33% and up to 305% for flour (Figure 2). In particular, the Bonferroni post hoc test highlighted significant differences between the mean prices of some products, such as biscuits, ice-cream and flour, obtained from large-scale retail stores and those found at the other retail channels. For the other shopping venues, specialist shops, pharmacies and on-line stores, prices are on average very similar. On-line store prices are slightly cheaper (Table 6), but the Bonferroni post hoc test did not show significant differences between these and specialist shops/pharmacies.

Figure 2: Percentage Price Difference between Gluten-Free Foods Found at Large-Scale Retail Stores Compared On-Line Stores.

 

 

Bread

Pasta

Biscuits

Pizza

Ice-cream

Flour

Large-scale retail stores

gluten-free

1.49 (±0.84)a

0.60 (±0.34)a

0.77 (±0.09)a

1.73 (±0.20)a

0.72 (±0.42)a

0.16 (±0.23)a

Specialist shops

gluten-free

1.60 (±0.00)a

0.64 (±0.00)a

1.24 (±0.10)b

1.85 (±0.27)a

1.34 (±0.00)b

0.70 (±0.00)b

Pharmacies

gluten-free

1.70(±0.08)a

0.68 (±0.03)a

1.08 (±0.10)b

1.96 (±0.33)a

1.34 (±0.00)b

0.72 (±0.03)b

On-line stores

gluten-free

1.74 (±0.12)a

0.70 (±0.05)a

1.02 (±0.17)b

1.87 (±0.27)a

0.70 (±0.67)b

0.67 (±0.05)b

Table 6: Mean Costs (€/100g) of Gluten-Free Foods Shown by Store Category and Results of Bonferroni Test.

a,b mean values within columns with different letters are significantly different (P = 0.05).

Comparison between prices of gluten-free and respective conventional foods

As a substantial price difference emerges between gluten-free and conventional products from studies carried out in Canada [18], the USA [19] and the UK [20], an evaluation was carried out to see what differences there were between these two types of product in Sardinia. For this purpose the basket of six gluten-free products analysed previously was compared with an identical basket consisting of conventional products.  By comparison conventional and gluten-free foodstuffs, the ANOVA statistical analysis considers highly significant (p-value = 0.0005) the differences. in price between the two types.

Considering each gluten-free product, the conventional counterparts proved cheaper. The highest percentage differences are observed for flour (average 595%±328.8) and the lowest for ice-cream and pizza (68%±59.75 e 98%±9.88 respectively), as shown in Figure 3. These price differences, though justified by the greater cost of raw materials and controls to avoid cross-contamination extended to the whole production chain, proved higher than those observed in other countries, e.g. Canada [21], the USA [22] and the UK [23], where on average gluten-free products were respectively about 268 %, 60% and 275% more expensive than conventional ones. The percentage differences in prices between the two categories of product sampled in Sardinia (average is about 344 %) is higher than those found in Canada and in the UK, whereas the USA these percentage differences are quite low.

Figure 3: Percentage Price Difference between Gluten-Free and Conventional Foods at Sardinian Shopping Venues.

Discussion

From what emerged from the survey it is noted that on the Italian territory there is no uniformity in the free distribution of gluten-free products which, being therapeutic diet products, are dispensed against medical prescription. The first discrepancy observed concerns the ceiling of expense which in various regions (Friuli Venezia Giulia, Trentino, Veneto, Piedmont, Tuscany and Aosta Valley) is higher than that stated in DM 4 May 2006 [17], thanks to the fact that these are regions with autonomous legislation boards. Differences are also seen in the management of vouchers and these affect the quality of the service given. In effect, in most regions a single monthly prescription-coupon is distributed which must be spent at a single retail outlet under contract with the respective Local Health Authority. This situation limits freedom of choice both as regards products and sales points where coeliac sufferers can obtain supplies. This is what happened in the region of Tuscany in 2013 on opening up to the large-scale retail trade [22]. To avoid this inconvenience many regions have embarked on a variety of initiatives. Liguria, Friuli Venezia Giulia, Emilia Romagna, Marche, Lazio, Umbria, Piedmont and Calabria regions have split up the prescription-coupons to enable those who use them to collect products throughout the month at all contracted sales points. This solution has not been adopted in the other regions for economic reasons; they consider there would be an increase in the cost of printing and accounts management if the Local Health Authorities split up prescription-coupons. To improve the service some regions (some Lombardy provinces and the Local Health Authority of Caserta) have replaced paper vouchers with a completely electronic system. This also has the advantage of reducing management costs of the vouchers and enabling those using them to obtain supplies at any authorized sales point, thus creating the prerequisites for greater competition on the gluten-free product market. From the comparison of the Italian situation with that of other European and extra-European countries, it is noted that Italian assistance represents a unicum: in Switzerland (personal correspondence with Coeliac Group of Italian Switzerland) coeliac sufferers receive a benefit to purchase diet foods up to the age of 20, and after that they can deduct these expenses when filling in their tax statement over and above a franchise of 5% of taxable income. In Spain (personal correspondence with Asociación de Celíacos y Sensibles al Gluten. Comunidad de Madrid) coeliac sufferers do not usually receive any benefits from the National Health System, with the exception of three regions - Navarra, where a monthly benefit of 90€ exists, and Valencia and Extremadura, where only individuals with a low income receive gluten-free products. In the UK (personal correspondence with Coeliac UK) coeliac sufferers can receive between 10 and 18 units of gluten-free products on National Health Service prescription as agreed by the Advisory Committee on Borderline Substances (an advisory non-departmental public body). Foods on prescription are generally staple foods in the diet, such as bread, pasta and flour, rather than confectionery/luxury items, processed meat products or sauces. Furthermore, in England people with coeliac disease still have to pay for prescriptions unless they meet the criteria for exemption (the following are exempt from prescription charges: children under 16 years of age; those in full-time education under 18 years of age; those over 60 years of age; pregnant women; NHS in-patients; those with a valid exemption certificate due to another medical condition; having had a baby in the previous 12 months or a physical disability; individuals on income support or other income related benefits). Whereas in Scotland, Northern Ireland and Wales prescriptions are free of charge. In Finland (personal correspondence with Finnish Coeliac Society) coeliac sufferers receive a supplement calculated on the difference in price between gluten-free and conventional (or ordinary) foods. A similar way of providing assistance has also been adopted in Canada (personal correspondence with Fondation québécoise de la maladie coeliaque), which is one of the few extra-European countries where a supplement is available.  Canadian coeliac sufferers are actually entitled to claim the incremental costs (the difference in the cost of gluten-free products compared to the cost of similar conventional foods) associated with the purchase of gluten-free products as a medical expense that can be deducted when filling in their tax statement. Total annual medical expenses have to exceed 3% of the net income. In Australia (personal correspondence with Sue Black Administration Coeliac Australia) and the USA (Celiac Disease Foundation) no type of assistance is currently available.

It can also be inferred from the analysis that, although the Italian National Health Service assistance system for coeliac sufferers is undoubtedly a situation not often found in other countries of the world, it has created a market where free competition is not favoured. The DM of 8 June 2001 provided for gluten-free product distribution against prescription-coupons at different retail outlets like specialist shops, large-scale retail stores, parapharmacies and pharmacies. Even though free distribution can take place at different retail outlets the pharmaceutical channel has been preferred, where 70% of gluten-free products are distributed [23]. There are various regions, including Basilicata, Campania, Molise, Sardinia, Sicily and Aosta Valley which still today do not provide for contracts between the Local Health Authority and the large-scale retail trade. This study has highlighted that the prices of products sold via the pharmaceutical channel and specialist shops are around 10-86% higher, with peaks at 330%, than those of large-scale retail stores. Thus, facilitating the purchase of these products at large-scale retail outlets would enable the local Health Authority to reduce its ceiling of expenses for monthly prescription-coupons, with a consequent saving in the costs of medical benefits for coeliac sufferers. This is what happened in the region of Tuscany in 2013 on opening up to the large-scale retail trade [24].

Favouring competition between the various retail channels would also lead to a reduction in prices of products for coeliac sufferers. As regards these markets, price differences between gluten-free products purchased through the various distribution channels and equivalent conventional foods also prove higher: from 68 to 98% with peaks of 416-595%. The reasons for these increases are always justified by the higher cost of raw materials, control activities to avoid cross-contamination extended to the whole production chain, and the need to improve the organoleptic properties of these foodstuffs. But, as reported by Italian coeliac sufferers [25] they cannot just be these. Undoubtedly, the fact that these products, being therapeutic diet foods, are subsidized by the State has notable repercussions on the gluten-free product market. In effect, since the State is actually paying, the price of products stays constantly high, and as the number of coeliac sufferers increases the price does not go down but on the contrary has tended towards an increase in recent years.

Conclusion

The study carried out has highlighted how coeliac sufferers in Italy do not enjoy the same treatment as regards the supply of therapeutic diet products. Different maximum limits of expense from region to region, monthly vouchers that are rarely split up and are to be spent at a single contracted sales point cause inconvenience to coeliac sufferers. In order to make the management of prescription-coupons more simple and immediate and enable the coeliac sufferer to obtain supplies at any authorized sales point, it would be appropriate to substitute paper vouchers with electronic systems as done by the Caserta Local Health Authority (electronic card) or some of the Lombardy provinces (WEBCARE system). Another critical issue concerns the distribution channels under contract with the National Health System. Although prices are higher at pharmacies they remain the preferred channel, in spite of the fact that an agreement may also be possible with large-scale retail stores, where prices prove much lower. To authorize the large-scale retail trade to freely dispense the products in those regions where this is not yet possible would lead, as well as having the clear advantage of “demedicalisation” of coeliac disease, to creating the prerequisites for greater competition, not to mention a reduction in price. This would create the conditions for reducing the monthly expense ceilings and consequently saving costs for the regional Local Health Authority. The survey has confirmed that also in the Italian regions the prices of gluten-free products are higher than those found on the foreign market. These results confirm that aberrations exist on the Italian market where demand proves to be inelastic compared with price.

Acknowledgments

Our thanks to Prof. Franco Mario Andrea for his critical reading of the work and precious suggestions, and to Dr Beba Molinari of the AIC Observatory on the quality of life of coeliac sufferers for her helpful collaboration.

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  8. Piedmont (2007) Circolare regionale Prot. n.8783/20.13 dell’11.
  9. Aosta Valley DGR 2791/2009 e DGR 160/2011.
  10. Tuscany DGR 1186/2012.
  11. Liguria DGR 1682/2005.
  12. (2012) Annual Coeliac Parliament Relation.
  13. Calabria DGR 230/2013.
  14. DGR 439/2008.
  15. Umbria DGR 1141/2011.
  16. Marche DGR 1232/2010.
  17. DM 4th May 2006.
  18. (2005) Norme per la protezione dei soggetti malati di celiachia.
  19. Lee AR, Ng DL, Zivin J, Green PH (2007) Economic burden of a gluten free diet. J Hum Nutr Diet 20(5): 423-430.
  20. Legge provinciale 8/2011.
  21. Registro Nazionale dei prodotti destinati a un’alimentazione particolare.
  22. Singh J, Whean K (2011) Limited availability and higher cost of gluten-free foods. J Hum Nutr Diet 24(5): 479-486.
  23. Stevens L, Rashid M (2008) Gluten-free and regular foods: a cost comparison. Can J Diet Pract Res 69(3): 147-150.
  24. Strinati M (2013) Senza glutine ma con prezzi da capogiro. Il salvagente 4: 19-23.
  25. Viganò EM (2013) La celiachia costa meno al supermercato rispetto alle farmacie: 20 euro di differenza in media per l’acquisto di 12 prodotti. Il fatto Alimentare.
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