Italy's National Health Service (Servizio Sanitario Nazionale, SSN) is facing a "perfect storm": chronic underfunding, demographic pressures seen across the world, a collapsing healthcare workforce, and widening regional inequalities.

Italy allocates only 6.4% of its GDP to public healthcare—a substantially lower percentage than the United Kingdom, France, and Germany.

Italy is divided into regions, and eight of them (primarily in the South) have required government financial rescue plans. These recovery programs include temporary hiring freezes, further straining already understaffed healthcare systems.

Out-of-pocket healthcare spending by Italian citizens has reached approximately 24% of total healthcare expenditure, a figure significantly higher than that of most Northern European countries. For a nation that has long taken pride in its publicly funded healthcare system, this represents a gradual erosion of universal healthcare and a failure of the public system, as patients are increasingly forced to seek private care—not by choice, but because of long waiting lists.

No Country for Old Men

More than half of Italy's physicians are over the age of 55, and the wave of impending retirements is not being offset by new graduates. This is largely due to restrictions on admission to medical schools and bottlenecks in residency training programs, which are funded by the regional governments.

Italy's nurse-to-population ratio is only half that of Germany. The country also faces a high rate of physician attrition among hospital doctors, often driven by job dissatisfaction.

In reality, Italy operates not one healthcare system, but twenty different regional healthcare systems. Southern regions consistently perform worse in meeting the country's Essential Levels of Care (Livelli Essenziali di Assistenza, LEA), driving increasing numbers of patients to travel north in search of treatment. Although the 2022 healthcare reform sought to standardize community-based healthcare delivery across the country, its implementation within a decentralized system has so far failed to eliminate these regional disparities.

How Do We Save Our Patient?

Our chronically ill National Health Service requires a structural increase in public healthcare funding, moving closer to the European Union average of approximately 7–8% of GDP.

More than €20 billion of SSN spending is absorbed by waste attributable to six major categories:

Overuse (unnecessary tests and treatments, often performed to reduce medicolegal risk)

Underuse (failure to provide evidence-based interventions)

Administrative complexity

Fraud

Non-optimal pricing

Missed opportunities for prevention

Admission caps to medical schools—and, where feasible, the length of medical training—should be gradually reduced. Similar restrictions on nursing school enrollment should also be eliminated.

Italy should establish a standardized, university-based postgraduate training pathway for primary care physicians. At present, primary care is still widely regarded as a "second-tier specialty," making it less attractive to young physicians.

The 2022 reform establishing Community Health Centers (Case della Comunità) and Community Hospitals (Ospedali di Comunità) represents the right direction: shifting healthcare from a hospital-centered model toward one rooted in community-based care. Successful examples already exist in regions such as Emilia-Romagna, Tuscany, and Veneto, but these models have not yet been fully implemented nationwide.

Finally, the continued expansion of voluntary private health insurance should be limited wherever possible, as it risks creating a two-tier healthcare system in which access increasingly depends on socioeconomic status.

Italy's National Health Service remains a healthcare system of remarkable value. Despite spending substantially less than comparable countries, it ranks ninth in the world on measures of healthcare access and quality.

The challenge is not to build an entirely new healthcare system, but to preserve the one that already exists before its slow erosion transforms Italy's universal healthcare system into one where access to care is determined by income.

Antonio Fratini MD is a pulmonologist at Cristo Re Hospital in Rome, Italy.