There is a fundamental misunderstanding that continues to poison the public debate on healthcare in Italy: the idea that simply “doing more” is enough to save the national health service (Servizio Sanitario Nazionale, SSN). More resources, greater efficiency, shorter waiting lists - these are reassuring, politically marketable slogans, but they are increasingly detached from reality.
The point is that today the SSN is not simply underfunded or inefficient. It is a universal system operating in a country that has changed profoundly, and its leaders continue to behave as if that change did not require explicit choices. The 2025 Rapporto OASI (in Italian) pushes us toward deeper reflection: In an environment where resources are scarce and will never again be abundant, the new emergency is the absence of stated priorities.
Italy currently has 26% fewer births than ten years ago, more than three million additional elderly people, around four million non-self-sufficient individuals, and a shrinking employment base. In other words, needs are growing while the collective capacity to finance them is declining. In this context, continuing to promise that “everything can be done” is illusory and dangerous.
A universal healthcare system cannot simply chase demand. It must govern demand. And that means deciding who comes first, which services to provide for them, and what level of care they need. It is not renouncing universalism; it is the only sustainable form of universalism in the twenty-first century.
Three comforting narratives
Yet the public debate continues to fall back on three comforting – and often contradictory -narratives. The first is that all we need to do is to increase funding. The second is that efficiency is a purely technical matter that we can solve without redistributive conflicts. The third is that eliminating waiting lists is the primary objective of a healthcare system. All three avoid the central issue: With limited resources and escalating needs, it is no longer possible to do everything, everywhere, for everyone, in the same way.
The signs of this failure to choose are already evident. Physician referrals for specialist visits or diagnostics systematically exceed the SSN’s capacity to deliver services; only a portion of them are done in public clinics and hospitals, while the rest fuel private spending. Patients who can’t afford to go private do without or find alternative healthcare pathways. Non-self-sufficiency is growing faster than available solutions, with marginal residential coverage and increasingly fragmented home care. Territorial inequalities persist, despite a substantially equitable distribution of financial resources. And the use of services varies unjustifiably among and even within regions, a sign that clinical need is not yet the true allocation criterion.
All this happens because the SSN is navigating without a shared compass.
The OASI Report identifies at least five areas in which the system can act immediately, without waiting for unlikely epoch-making reforms. The first concerns personnel: attracting and retaining nurses, reducing professional fragmentation, and realigning training with actual needs. The second is updating tariffs for accredited private providers, which are often misaligned with policy priorities. The third is a stronger and more qualified commissioning function vis-à-vis providers of healthcare services and health-related goods, more appropriate to the role of major purchaser that the SSN now plays. The fourth concerns digitalization: The decision must be made whether to fully adopt a “digital & remote first” model or continue to oscillate between ungoverned hybrid solutions. The fifth is proximity, understood not as a multiplication of physical sites, but as multichannel continuity of care, with a stable point of contact for citizens.
The courage to say it
In this scenario, the role of health care management becomes central. The absence of explicit political priorities opens a space of autonomy that is both an opportunity and a responsibility. General managers in the healthcare system find themselves juggling a double agenda: a visible one, oriented toward budgets, volumes, and waiting times; and a strategic one, less exposed but decisive, concerning the reallocation of resources, the reduction of unjustified variability, and the comprehensive management of chronic and frail patients.
It is on this second agenda that the future of universalism will be decided. Because universalism is not the promise of everything for everyone, but the guarantee that those who need it most are not left behind.
The Italian SSN still has an extraordinary wealth of skills, values, and social consensus. But to preserve it, we must abandon the illusion that we can postpone critical decisions indefinitely. The situation is at a breaking point, and pretending otherwise does not make it any better. The real reform today is having the courage to speak the truth and to occupy the vast spaces of professional and managerial autonomy that inconsistent narratives and policies have created.
Francesco Longo, Alberto Ricci, “La sanità italiana: narrazioni consolatorie, criticità governabili e una doppia agenda manageriale,” in CERGAS (a cura di), Rapporto OASI 2025, Osservatorio sulle Aziende e sul Sistema sanitario Italiano, EGEA, 2025.
