Tell me the truth about the Italian NHS: Four steps toward sustainable universality

By defining itself as universal, the Italian National Health Service (INHS) promises to be all things to all people. But in reality, it ends up offering a mix of everything to only a select few, fostering dissatisfaction and inequality.

With public funding at 6.3% of GDP, Italy is unable to meet the (high) expectations of its citizens. Even other major European countries, which allocate between 9% and 11% of GDP to healthcare, struggle to do so. Ironically, the public healthcare systems of Western nations are victims of their own success, having significantly contributed to extending healthy life expectancy in recent decades. This achievement, combined with low birth rates, is responsible for an aging population and rising healthcare needs.

The dominant narrative around underfunding is accompanied by two pieces of fake news that hinder a full understanding of the situation by both citizens and practitioners.

The first myth is that the NHS budget has always been limited, yet needs were better met in the past. While it’s true that funding has remained around 6-6.5% of GDP for years, demographic and epidemiological changes have shifted the landscape. In 2004, people over 65 made up less than 19% of the population; by 2024, this figure jumped to 24%. In absolute terms, the number of over-65s has ballooned by 30% in two decades. To grasp the cost burden of an aging population, consider that at age 65, eight out of ten Italians suffer from at least one chronic illness.

The second myth is that healthcare spending can be easily expanded. An aging population both worsens epidemiological issues and redirects resources toward pensions. That means pension spending crowds out funding for education, transport, and healthcare. Aligning Italy’s healthcare expenditure with that of its European peers would require an additional €40 billion per year—half of the country’s current annual education budget. Meanwhile, pension spending is projected to rise by nearly €50 billion between 2023 and 2027…

If the INHS can’t provide comprehensive universal coverage, it must establish priorities to use its resources more efficiently. However, the 2024 OASI Report highlights a lack of prioritization, which exacerbates inequalities. Those better able to navigate the system obtain services and reimbursements, while those who are socially disadvantaged cannot. Among chronic patients over 65, 43% of university-educated individuals report good health, compared to only 22% of those with primary education.

Non-self-sufficient elderly individuals are among those left behind by the INHS, A cohort which currently counts 4 million Italians.  Assuming an average of two family caregivers per individual, the issue affects 12 million people. Yet there are only 300,000 nursing home beds, and families must supplement public coverage with an average of €24,000 per year for long term care facilities, clearly favoring wealthier households.

Beyond the lack of awareness and prioritization, a third problem lies in the extreme variability in healthcare consumption and prescriptions, even when epidemiological conditions are similar. For example, laboratory tests per capita in Brescia are double those in Bergamo. Similarly, diagnostic exams in Emilia-Romagna are double those in Lombardy. The INHS also prescribes more than it can deliver. In some local areas and for specific services, prescriptions for care amount to double the system’s capacity to provide it.

The OASI Report outlines four strategic actions to move toward a more sustainable universal healthcare model—one where the INHS provides the services it can actually deliver, guided by clear priorities.

• Manage expectations: Defining the limits of the INHS and revising priority criteria for essential services is a critical first step. Giving precedence to care for chronic patients and those with low self-sufficiency, while clearly communicating guaranteed services, would simplify the system and improve access. This alignment would help close the gap between prescribed and deliverable care.
• Unpopular efficiency: Transform small hospitals into more effective community healthcare service centers, consolidate redundant outpatient clinics and labs, and reorganize underperforming hospitals. While politically challenging, such measures are essential to improving system quality and sustainability.
• Raise INHS resources: Implement initiatives already tested in other countries, such as increasing co-pays for certain services, introducing mandatory supplementary insurance, or reallocating public spending to provide additional healthcare funds. Though politically complex, these steps are vital to augmenting INHS funding.
• Radical innovation: Accelerate the digital transformation of healthcare through tools for self-managing chronic conditions and telemedicine for specialist visits. Redesign professional positions to enhance collaboration between traditional and emerging competencies, creating roles such as administrative case managers for integrated chronic care management.

A more realistic narrative about the INHS, as tough as the one outlined in the OASI Report, is necessary to drive the cultural shift required for a more equitable, efficient, and sustainable system. Without open dialogue among institutions, professionals, and citizens about the real capabilities and priorities of the INHS, the risk is perpetuating a system that promises too much but delivers too little—widening inequalities and eroding trust.