Can universalism in the Italian healthcare system be made sustainable?

The Italian National Health Service (Servizio Sanitario Nazionale, SSN) has long been one of the least funded in Europe, with public health spending at just 6.3% of GDP, despite Italy being the second oldest country in the world. To bring Italian public healthcare in line with that of major European nations, at least €40 billion would be required—equivalent to half of the country’s current annual education budget. This is an enormous figure, especially given a challenging demographic scenario characterized by high pension expenditures and a shrinking working-age population.

These are some of the key findings of the 2024 edition of the Osservatorio sulle Aziende e sul Sistema sanitario Italiano (OASI), published today by the CERGAS research center at SDA Bocconi School of Management. The report was unveiled at an event featuring 33 speakers and attended by 1,800 healthcare managers.

Now in its 25th edition, the OASI report has become a cornerstone for analyzing changes in the SSN and the broader Italian healthcare system. It provides a snapshot of the system's current state and proposes measures to address its most pressing challenges.

The analysis, conducted by a research team led by Francesco Longo, Associate Professor at Bocconi University, and Alberto Ricci, Associate Professor of Practice at SDA Bocconi, highlights the SSN's critical issues. Although designed as a universal healthcare service, the SSN struggles to meet the growing needs of its citizens, particularly for the chronic population (41% of residents) and the elderly who require long-term care (4 million people).

“Italian healthcare is at a turning point,” said Francesco Longo. “Italy is now the second oldest country in the world. Healthcare spending has remained stagnant, while citizens' needs are evolving, and they expect a sustainable and efficient service. However, the SSN's contradictions are evident and will worsen without a systemic governance overhaul, weakening the foundation of SSN organizations.”

While France, Germany, and the United Kingdom allocate 9-11% of GDP to their healthcare systems, Italy has consistently remained at around 6.3% of GDP, a figure projected to stay stable through 2025 and 2026. Surprisingly, even private healthcare spending has grown less than GDP, at 2.2% in 2024—about 26% of total healthcare expenditures. The data is clear: Italy is unwilling to invest in health, either publicly or privately.

The SSN’s primary challenge is ensuring the sustainability of universal access. Acknowledging this constraint is essential to reorganizing the system, where service access priorities are often random, ineffective, and inequitable. For example, the likelihood of seniors remaining in good health is halved when comparing those with university degrees to those with only primary education. Similarly, healthcare service utilization can vary by as much as 100% across similar territories within the same region. The gap between prescribed and deliverable services damages the SSN’s reputation and undermines its effectiveness.

To address these challenges, the OASI Report 2024 outlines four policy approaches that, implemented individually or in combination, could significantly improve the SSN and its ability to support citizens:

• Managing expectations: Clearly defining the SSN's limitations and refining criteria for prioritized services is a crucial first step to align public expectations with available resources. Focusing on key target groups, such as chronic patients or those with low self-sufficiency, and communicating guaranteed services transparently would simplify the system and improve access. This approach would gradually narrow the gap between what the SSN prescribes and what it can realistically deliver.
• Unpopular efficiency: Optimizing the hospital network by repurposing smaller, fragmented facilities into community services; consolidating outpatient services and laboratories in areas with an excessive number of facilities; and addressing mid-sized hospitals that fail to meet the volumes needed for quality and sustainability. For example, creating or renewing Community Healthcare Hubs represents a major opportunity to integrate and streamline previously fragmented local services.
• Increasing SSN resources: Drawing on strategies tested in other countries, such as higher co-payments for certain services, supplementary insurance for reimbursements, or reallocating public spending to increase healthcare funding. These proposals are challenging to implement within Italy’s current political and social context.
• Revolutionizing service geography and formats: Expanding digital health services for specialized care, promoting self-management tools for chronic patients, and adopting telemedicine systems for specialist consultations. Redesigning professional roles by fostering horizontal collaboration and integrating new competencies with traditional professions—such as introducing case managers to coordinate chronic care—would also be transformative.

“Awareness of the current scenario, despite its complexity, is the first tool SSN managers have to grow and remain generative,” concluded Alberto Ricci. “Our report lays the groundwork for dialogue among all stakeholders in the Italian healthcare system and, ideally, for charting a new course at the national level.”

SDA Bocconi School of Management