Over-the-counter drugs are paid out-of-pocket. Both prescription and over-the-counter drugs can only be sold in specialized shops (farmacia). In a sample of 13 developed countries Italy was sixth in its population weighted usage of medication in 14 classes in 2009 and fifth in 2013. The drugs studied were selected on the basis that the conditions treated had high incidence, prevalence and/or mortality, caused significant long-term morbidity and incurred high levels of expenditure and significant developments in prevention or treatment had been made in the last 10 years. The study noted considerable difficulties in cross border comparison of medication use