Over the past fifteen years, Italy’s National Health Service (SSN) has gradually adapted to operating within a resource perimeter that is defined and difficult to expand. Allocation choices made in recent years and current policy outlooks confirm that health expenditure as a share of GDP remains stable at around 6.3–6.6%, the lowest level among major European countries.
A clear picture emerges: modest levels of spending in one of the oldest countries in the world, with limited—if not nonexistent—room for future expansion. It is a perimeter within which the system is expected to operate on a stable basis. In this context, the SSN has developed a solid ability to realign expenditure with available resources, maintaining contained deficits over the past fifteen years (around or below 0.5% of funding) and thereby consolidating overall financial balance.
What lies behind this system-wide balance?
The consolidation of financial equilibrium is accompanied by several structural dynamics, which become evident when jointly examining sources of funding, methods for valuing output, and the operating conditions of regional and organizational levels.
A first aspect concerns the growing gap between central SSN funding and the actual expenditure incurred by regional health systems (SSRs). Regional intervention through own-source funding and the resulting activation of self-financing policies mitigate this effect, although the ability to allocate additional resources is also gradually declining for regions. Moreover, in 2024 nine SSRs still record deficits, with particularly significant figures in Tuscany, Sardinia, Emilia-Romagna, and Piedmont.
At the same time, the “productivity” of SSRs has declined compared to the pre-pandemic period. When relating the value of inpatient and outpatient specialist services to total health expenditure incurred by different SSRs, only 30% of that expenditure is “converted” into services delivered, down from 35% in the pre-pandemic period and with wide interregional differences (from 33–34% in Emilia-Romagna and Lombardy to 23–24% in the Autonomous Province of Bolzano, Calabria, and Sardinia). While this metric may be useful for comparisons over time and across regions, it highlights how reasoning in terms of “services” is outdated and fails to capture how services actually function.
The same dynamic emerges at the organizational level. Public healthcare providers face significant pressure on production costs and increasing dependence on transfers from higher-level entities, which do not directly correspond to the volume and mix of services delivered. In large public hospital organizations, for example, services account for about 61% of the value of production (with variability ranging from 42% to 76%), while the remaining share is effectively supported by transfers.
These elements risk entrenching a divergence between financial balance (ensured by “extra” funding sources) and the economic balance of organizations, that is, their actual capacity to generate productivity and efficiency. This creates an uneven competitive environment among organizations (with greater or lesser efficiency largely not reflected) and risks undermining the very logic of corporatization, which is based on managerial autonomy and accountability for results.
Policy workstreams for governing the system
There are three possible governance logics that can be activated to reinvigorate incentives for increasing the value generated by regions and organizations.
A first, now well-established logic is to act on the control of production factors. This input-based control ensures alignment between spending and available resources but does not generate incentives to improve efficiency or to truly transform services.
A second logic should push toward the activation of resource reallocation processes that support innovation and transformation in service delivery models. Consistently, a third logic should promote overcoming the current “service-based” approach in favor of care pathways aligned with the growing prevalence of chronic conditions and socio-health needs, defining clear priorities in terms of target populations and sustainable levels of care intensity.
These three logics must coexist, striking a balance among the forces that combine overall spending control, reallocation, and innovation in service and work models. Promoting bundled care approaches remains a complex task in a system that is not accustomed to operating across silos. From this perspective, it is worth asking what the “places” and “levels” of innovation might be—namely which territories, actors (regional level, healthcare organizations, districts), and professional roles (top or middle management, healthcare professionals) are capable of leading and spreading effective change processes. At the same time, we must reflect on which metrics the SSN needs today, moving beyond a service-based approach in order to better capture how services function, their critical issues, and the system’s capacity to address them.
Alessandro Furnari, Elisabetta Notarnicola, Giordana Puritani, Alberto Ricci, Silvia Rota. “La spesa sanitaria e i costi dei servizi: composizione ed evoluzione nella prospettiva nazionale, regionale ed aziendale.” (Health expenditure and service costs: composition and evolution from national, regional, and organizational perspectives). In Rapporto OASI 2025 (in Italian).
