Il National Health Service (SSN) Italian is going through the crisis more serious since its establishment in 1978, a critical moment that highlights the paradox of "too much" and "too little". On the one hand, the demand for health is growing because ofpopulation ageing, which in 2050 will see the number of over 65s triple compared to under 14s, with a significant increase in people who are not self-sufficient or have chronic pathologies. On the other hand, theservice offering is decreasing, burdened by the shortage of healthcare personnel, particularly in medical and nursing specialties, which has not been adequately addressed. The research “The health system in Italy” promoted by Intesa Sanpaolo and made by Census e Italiadecide also highlights the use of Industrial expensive and low-quality, such as the use of cooperatives to fill the gaps, and the increase in access to private sector, phenomena that further accentuate the crisis.
To this are added the very long waiting times for health services, a symptom of structural dysfunctions in the system. In 2022, live births in Italy were less than 400 thousand, with a birth rate of less than 7 per thousand inhabitants, and in 2050 it is expected that for every child there will be three elderly people. These demographic changes make a systemic response urgent.
The public health crisis
The NHS has shown signs of crisis for years, mainly in due to underfunding. In 2018, on the occasion of the 40th anniversary of the system, publications such as Sustainable health by Marco Geddes from Filicaia underlined the economic sustainability of the health system, denying the narrative according to which it was too expensive. On the contrary, the health care spending has been constantly reduced, putting its efficiency at risk.
Two factors have accentuated the crisis: the pandemic, which has aggravated the structural deficiencies of the system, and the already foreseeable lack of staff, especially medical. Despite this, until 2019, the Italian public health system was among the best in Europe in terms of life expectancy and avoidable mortality. The pandemic has highlighted the fragility of the system, reducing life expectancy and interrupting many essential health services.
In summary, although the Italian healthcare system performed well pre-pandemic, structural challenges, combined with the impact of Covid-19, require urgent reforms and investments.
Underfunded Healthcare in Italy: A Chronic Problem
The Italian National Health Service spends less compared to many European countries, such as Germany and France, both in terms of GDP and public and private investment. Despite this, no significant increases in resources are expected.
The consequences? Staff shortage, rising costs e difficulties in implementing reforms such as territorial assistance. According to Crea Sanità, 15 billion euros per year for five years would be needed to align with European standards, compared to the only 2 billion foreseen.
Health spending review
La health spending review, introduced in 2010, imposed a spending cap for healthcare personnel, set at 2004 levels and reduced by 1,4%. Despite some adjustments, the limits have remained unchanged. This measure, part of a broader plan to rationalize resources and reduce inefficiencies, has had devastating effects. From 2010 to 2019, the NHS lost 37 billion euros, with significant cuts especially between 2010 and 2015. The reductions also affected hospitals, beds and staff, leading to the closure of 100 hospitals and an increase in private facilities, contributing to the current problems of the healthcare system.
Staff shortage
La staff shortageand healthcare in Italy is the result of a policy of savings that began in 2010. In 2020, Italy had only 34,3 doctors for every 1.000 elderly people, compared to the European average of 38,5, and 48,9 nurses for every 1.000 elderly people, a number much lower than other countries. The shortage of personnel, especially specialized nurses and doctors, is linked to an inefficient training system and the "flight to the private sector" for better working conditions. The result is a fragile NHS, with a expensive use of temporary doctors to plug the gaps.
The role of the private sector in healthcare
Il private accredited play a role significant in public health, particularly in the chronic and long-term care sectors, with spending of 17,4% in 2021. It focuses mainly on scheduled surgery, while the public manages emergencies and more complex cases. However, the expansion of the private sector raises concerns on sustainability of the system and on the risk of attracting professionals from the public sector, which could worsen the already serious shortage in the NHS, particularly in areas such as surgery and anaesthesia.
The real challenge is integrate public and private in a balanced way, enhancing the potential of the private sector without compromising the universalism of public health. This requires action to improve working conditions and remuneration in the public sector, increasing the attractiveness of healthcare careers, and a model of collaboration with the private sector that respects the principles of equity and quality.
Health in the social context
The study also highlights some demographic phenomena that are crucial for the future of the Italian healthcare system. Among these, one of the most relevant is the so-called demographic winter, which began in 2014, when the Italian population began to decline. In January 2022, there were approximately 59 million residents, a reduction of 2,2% compared to 60,3 million in 2014. Forecasts indicate that, in the next 20 years, the percentage of people over 65 will represent 34-35% of the population, with a ratio of 300 elderly people for every 100 young people.
This demographic evolution will have direct repercussions on non-self-sufficiency, with an increase in the number of elderly people requiring assistance. Today, approximately 3 million people in Italy have serious limitations that prevent them from carrying out daily activities, a figure that is set to grow, particularly among the over-74s, who in 2040 could represent more than half of the population with serious disabilities.
Territorial gaps and inequalities in access to health
In addition to demographic challenges, another problem that is emerging forcefully is that of territorial gaps in the provision of health services. These disparities, accentuated by the pandemic, are also linked to poverty, which continues to grow, especially among the youngest and most fragile. Territorial and social gaps in access to care create conditions of inequality that undermine the effectiveness and efficiency of the national health system, requiring targeted interventions and greater collaboration between the public and private sectors.
Public and private in healthcare: what changes with the PNRR?
The pandemic has shown the limits of public health, now at the center of "extraordinary maintenance" thanks to the PNRR. With health spending below the EU average, a quarter of doctors over 65 and few nurses, the system must evolve.
Le main novelties of the PNRR include:
- Community Homes and Hospitals, to bring care closer to citizens and reduce unnecessary hospitalizations;
- Telemedicine, with digital services such as televisits and telemonitoring;
- Public-private collaboration, to innovate through startups and new technologies.
Today, the private sector integrates the NHS with supplies, accredited services and insurance, while the Third Sector can fill organizational and economic gaps. The challenge? Building an inclusive, sustainable and citizen-friendly healthcare system, with the public and private sectors in synergy.
Healthcare in crisis: the solutions
Research suggests making more efficient health spending, eliminating waste and improving planning based on demographic projections, with a serious commitment to increasing the effectiveness of the system. As regards the offer, it is crucial to relaunch the appeal of the health professions and promote integration between health and assistance, also attracting workers from abroad, with a central role for the Third Sector. Furthermore, the digitization of the NHS and the secure management of health data are key points for a more modern and efficient healthcare system.
“There is a need not only for 'more' (staff, salaries, resources), but also for 'less' (rigidity, waste, duplication)”, he stresses Daniela Viglione, scientific director of italiadecide. On digitalization, she then highlights the importance of "strengthening attention to the security of health data and privacy, essential to research and health management". The study also focuses on "territorial gaps, from health emigration to regional supply-demand imbalance", she explains Andrea Thomas, head of the Economy, Work and Territory Area of Censis, who in the report highlights the need to "act on phenomena of poverty, marginalization and indigence" and to "develop collaboration between the public, private and Third Sector".
