Il National Health Service remains founded on the principles of universality and equity, but in numbers it resembles less and less to a system supported predominantly by the public handThis is the photograph taken by theParliamentary Budget Office in the Focus “Public and private healthcare in Italy: financing, production and businesses“, published at the end of March. The picture that emerges is that of a increasingly hybrid healthcare, where is the public funding remains below 75% Of the total, household spending weighs more than in the rest of Europe and a significant share of public resources ends up with private suppliers.
A health service increasingly less supported by the public
In comparison with other European countriesItaly shows a clear imbalance. In 2023, the National Health Service (NHS) covered 73,1% of total healthcare spending, while the European Union average exceeds 80%. On the other hand, the direct burden of families is growing, with out-of-pocket spending rising to 23,6% of the total, nearly nine percentage points above the European average. This gap, according to the UPB analysis, raises potential challenges in terms of equity and efficiency.
Making the change of structure even clearer is also thetrend of public funding compared to GDP. Between 2012 and 2024 theincidence has progressively decreased, stopping at 6,3% in the last year. At the same time, supplementary healthcare has strengthened. members of private health funds They have almost tripled in ten years, going from 5,8 million in 2013 to 16,3 million in 2023. This expansion signals that a growing portion of the demand for healthcare is seeking solutions outside the strictly public sphere.
The burden of taxes and the growth of the healthcare market
Public support for the sector does not only come from direct state spending, but also from tax systemIn 2023, the overall intervention through deductions and incentives reached approximately 6,1 billion. Of these, 4,6 billion are linked to deductions for health expenses, with benefits concentrated especially among employees with medium-high incomes. intermediated healthcare Instead, they are associated with a reduction of 1,1 billion in IRPEF revenue and approximately 0,6 billion in reductions in social contributions, compared to an increase in income tax revenue of 0,2 billion.
The Upb thus highlights a double movementOn the one hand, the public sector is declining in terms of overall coverage, while on the other it continues to support the system through tax incentives that encourage the use of supplementary instruments. It is within this delicate balance that the growth of the private sector, which today iIt accounts for approximately one third of public health spendingA fact that speaks of a structural, no longer episodic, transformation of the Italian model.
Less staff, more external purchases
The transformation can also be read inside the production of health servicesBetween 1995 and 2024, the public sector's share of value added decreased by approximately five percentage points. The sharpest decline occurred between 1995 and 2017, with a decline of 7,6 percentage points, only partially recovered subsequently and more sharply during the pandemic years.
Over time health expenditure has moved ever closer to thepurchase of goods and servicesOutsourcing, the use of flexible working, including so-called "token workers," and the acquisition of services from private entities have increased. During the same period, changed also the weight of the different welfare itemsPharmaceutical care through affiliated pharmacies has lost more than ten percentage points, while direct supplies from health care providers have increased. The share of hospital services within public production has also decreased by approximately ten percentage points, in line with the dehospitalization process.
On the employment front, the period 2009-2017 was marked by a cuts of approximately 46.500 NHS employees, a contraction that favored theexpansion of private offeringsAfter the pandemic, a reversal of trend was seen, with 64.800 more units between 2018 and 2024. But the recovery is not enough to erase the fragilities. Questions related to the low attractiveness of salaries and working conditions in the public sector.
A 69 billion sector that outperforms the public sector
A real industrial chain now revolves around healthcare. In Italy, the health sector generates approximately 69 billion in added value, equal to 6,4% of the total production by businesses, and provides employment to approximately 1,2 million people. Within this universe, however, growth rates are not the same for everyone.
Profitability appears to be increasing in the medical device manufacturing and pharmacy sectors, while healthcare provision remains highly labor-intensive, with productivity per employee lower than that of technology-intensive manufacturing industries. Among joint-stock companies, specialty care and diagnostics stand out, both of which have shown high levels of profitability, although diagnostics has seen a decline in 2022-2023. However, the recovery of hospital and residential services is more challenging, as they have yet to fully regain pre-pandemic levels of activity and profitability.
Overall the private sector confirms itself as "dynamic and expanding", with increasingly visible concentration processes in sectors such as medical devices, diagnostics, residential services and pharmacies. And this is precisely where theUpb's background warning.
The private sector, the Focus notes, cannot be superimposed on the public sector because it responds to different logics and objectives. Therefore, any further integration between the two worlds must be carefully evaluated to prevent the balance between market and universal protection from undermining the founding principles of the National Health Service.
