We won't save Italy's National Health Service with nostalgia: 20 proposals for change - now

Every time there is talk of reforming Italy's National Health Service (SSN), a defensive barrier immediately goes up. Any proposal for change is interpreted as an attempt to dismantle one of the pillars of the welfare state. That reaction is understandable, but today it risks becoming the greatest obstacle to the survival of the SSN.

Defending the SSN today means ensuring that, even twenty years from now, it will continue to guarantee the right to healthcare enshrined in the Italian Constitution.

But by pretending that nothing has changed since the system was established nearly fifty years ago, we are betraying the very principle of universalism that we claim to defend.

The Italy of 1978 no longer exists. We are living longer and spending decades with chronic diseases (an average of 28 years). Long-term care has become a mass phenomenon affecting four million people and technology has transformed diagnosis and treatment. Demographic trends are making it increasingly difficult to finance a welfare system that was designed back when the ratio between the working-age population and older adults was completely different. (Today, older adults outnumber children by two to one.) The bottom line is, we can’t address new challenges with an organization designed for the old Italy. For this reason, together with SSN scholars from fifteen universities, a large group of healthcare executives, and two foundations, we have put forward a reform proposal in which we rethink the very notion of protecting people’s health.

The first change concerns prevention. Today we continue to concentrate resources, expertise, and organization on treating disease, even though we now know that a significant share of health is accumulated long before a person goes into a hospital. The environment, education, work, nutrition, the quality of our cities, and social conditions are among the most vital determinants of health. For this reason, we recommend that every major public policy decision also be evaluated for its impact on health, by genuinely adopting the "Health in All Policies" approach.

The second change concerns the meaning of universalism. Since it is impossible to guarantee everything for everyone, we believe that universalism today translates into guaranteeing each person what they truly need. The current system already produces implicit rationing: On paper, everyone has the same rights; in practice, people with higher income, education, and skills can access care much more easily than others. Waiting lists, fragmented care pathways, and the difficulty of navigating different services are already creating an unequal healthcare system.

True equity means designing different services for different needs, with particular attention to the most vulnerable people and those least able to ask for the care they need.

That is why we advocate promising only what the system can actually deliver.

Any given right exists only if it can truly be exercised. By continuing to expand the Essential Levels of Care (LEAs) on paper without securing the necessary funding, professional healthcare providers, and organizations, we are simply creating expectations that inevitably turn into disappointment, forgone care, and inequality. This is also where political accountability comes into play. The LEAs, the relative funding, and the levels of coverage they provide must be defined as a package deal. Every promise must be backed by the resources needed to fulfill it. Every priority-setting decision must be explicit and transparent. And policymakers must have the courage to explain to citizens how resources are being used, knowing that those resources will inevitably remain limited.

Naturally, all of this also requires greater public investment. For years, Italy has devoted a smaller share of its GDP to healthcare than many other major European countries, so funding must gradually be brought into line with the EU average.

But it would be an illusion to think that more resources alone will be enough. We must govern the system more effectively; improve national and regional planning; enhance managerial expertise; integrate hospitals, community-based care, and social services once and for all; make intelligent use of the vast amount of fragmented health data; and invest in healthcare professionals, research, and innovation.

In addition to all this, we must recognize that protecting people’s health involves a wide range of actors. Of course, the SSN remains the cornerstone of the system, but it operates within a broader ecosystem that includes research institutions, universities, life sciences companies, third sector organizations, supplemental health funds, and private providers. Ignoring this reality hinders our ability to govern the system effectively.

The SSN remains one of the Republic's greatest achievements, and precisely for that reason it deserves a reform that measures up to the demographic, epidemiological, technological, and social transformations we now face. If we want to prevent the right to healthcare from becoming fiction, we must have the courage to rethink the tools through which we make that right a fact. Delaying this discussion any longer means allowing the National Health Service to grow weaker year after year, until reality—not reform—ultimately determines its transformation.

Click here to read the 20 proposals (in Italian).

The signatories:

Adinolfi Paola , Full Professor, Dipartimento di Scienze Aziendali - Management & Innovation Systems, Università degli Studi di Salerno and Director of CIRPA. 

Anessi Pessina Eugenio , Full Professor, Dipartimento di Scienze dell’Economia e della Gestione Aziendale, Università Cattolica del Sacro Cuore. 

Barresi Gustavo , Full Professor, Dipartimento di Economia, Università degli Studi di Messina. 

Benvenuto Marco , Associate Professor, Dipartimento di Scienze dell’Economia, Università del Salento. 

Borgonovi Elio , Professor Emeritus, Dipartimento di Scienze Politiche e Sociali, Università Bocconi, Founder and President of CERGAS – SDA Bocconi. 

Botti Antonio , Full Professor, Dipartimento di Scienze Aziendali - Management & Innovation Systems, Università degli Studi di Salerno. 

Brignoli Ovidio , General Practitioner and President of Fondazione SIMG. 

Campostrini Stefano , Full Professor, Dipartimento di Economia, Università Ca’ Foscari Venezia. 

Cepiku Denita , Full Professor, Dipartimento di Management e Diritto, Università degli Studi di Roma Tor Vergata. 

Costa Giuseppe , Professor Emeritus, Dipartimento di Scienze Cliniche e Biologiche, Università di Torino. 

D’Angela Daniela , Faculty Member, Università degli Studi di Roma Tor Vergata and Head of Research and the HTA, Medical Devices, and PDTA Area at C.R.E.A. Sanità. 

Derrico Pietro , Founder and Sole Director of ConsulHTA Srl. 

Draghici Tudor , Director, UOC Direzione Medica di Presidio, ASST Pini CTO. 

Frittelli Tiziana , Extraordinary Commissioner, GOM Reggio Calabria. 

Giordano Filippo , Full Professor of Economia Aziendale, Università LUMSA di Roma. 

Gonzato Ornella , Founder and President of Fondazione Paola Gonzato ETS. 

Gori Cristiano , Full Professor, Dipartimento di Sociologia e Ricerca Sociale, Università di Trento. 

Landi Stefano , Associate Professor, Dipartimento di Economia Aziendale, Università degli Studi di Verona. 

Longo Francesco , Associate Professor, Dipartimento di Scienze Politiche e Sociali, Università Bocconi and Director of the Osservatorio OASI of CERGAS - SDA Bocconi. 

Maino Franca , Associate Professor, Dipartimento di Scienze Sociali e Politiche, Università degli Studi di Milano and Scientific Director of Percorsi di Secondo Welfare. 

Marsilio Marta , Full Professor, Dipartimento di Scienze Biomediche e Cliniche, Università degli Studi di Milano. 

Marzulli Michele , Associate Professor, Dipartimento di Economia, Università Ca’ Foscari Venezia. 

Masella Cristina , Full Professor, Dipartimento Ingegneria Gestionale, Politecnico di Milano, Scientific Director of Osservatorio Sanità Digitale. 

Mauro Marianna , Full Professor, Dipartimento di Medicina Sperimentale e Clinica, Università di Catanzaro Magna Graecia. 

Monchiero Giovanni , Former Director General of Ospedale Molinette and President of FIASO. 

Montefiori Marcello , Full Professor, Dipartimento di Economia, Università di Genova. 

Noto Guido , Full Professor, Dipartimento di Economia, Università degli Studi di Messina. 

Nuti Sabina , Full Professor of Economia e Gestione delle Imprese at Centro Interdisciplinare Health Science, Founder of the Laboratorio Management e Sanità of Scuola Superiore Sant’Anna di Pisa. 

Petralia Paolo , Director General of AOUI di Verona. 

Pignataro Giacomo , Full Professor, Dipartimento di Economia e Impresa, Università di Catania. 

Polistena Barbara , Faculty Member, Università degli Studi di Roma Tor Vergata and Head of Research at C.R.E.A. Sanità. 

Reina Rocco , Full Professor, Dipartimento di Giurisprudenza, Economia e Sociologia, Università degli Studi Magna Græcia di Catanzaro. 

Ricciardi Walter , Full Professor, Dipartimento Scienze della Vita e Sanità Pubblica, Università Cattolica del Sacro Cuore. 

Romiti Anna , Researcher, Dipartimento di Scienze per l’Economia e l’Impresa, Università degli Studi di Firenze. 

Schiavone Francesco , Full Professor, Dipartimento di Studi Aziendali e Quantitativi, Università degli Studi di Napoli Parthenope. 

Spandonaro Federico , Adjunct Professor, Dipartimento di Economia e Finanza, Università degli Studi di Roma Tor Vergata and President of the Scientific Committee of C.R.E.A. Sanità. 

Vagnoni Emidia , Full Professor of Economia Aziendale and Director of the Centro di Ricerca Economia Sanitaria, Università degli Studi di Ferrara. 

Vainieri Milena , Full Professor of Management and Director of the Laboratorio Management e Sanità of Scuola Superiore Sant’Anna di Pisa. 

Venturini Alessandra , Full Professor, Dipartimento di Culture, Politica e Società, Università degli Studi di Torino. 

Fondazione Giovanni Lorenzini Medical Foundation. 

Fondazione Paola Gonzato ETS.