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Among European health-care systems, the Italian National Health Service (Servizio Sanitario Nazionale [SSN]) is seldom considered in comparative analyses of health-care system functioning despite high health outcome performance indicators, but the history, evolution, and current governance of 20 different, highly decentralised, region-based delivery systems make it a unique situation in which to gain insight, worthy of greater attention. In addition, its unenviable standing as the earliest, hard hit European nation during the first wave of the COVID-19 pandemic has provided a window on the first responses to this global public health disaster.
The Italian experience has been used to highlight the drawbacks and limitations of the country's response, suggesting that others should learn from Italy's mistakes.1 It has been argued that specific aspects of the context of the Italian health service have led policy makers to make numerous errors in managing the pandemic, leading the country into a health-care disaster. Although the Italian reality has been shown to be far from a disaster and a failure comparatively, the pandemic has unequivocally highlighted the long-standing weaknesses of the health-care system and helped identify its future challenges. No better occasion is given to the Italian Government than the Next Generation EU, the recovery plan of the EU,2 which could permanently address the vulnerability of the SSN and strengthen its founding principles: universalism, equity, and solidarity. Whether the future shape of the SSN will continue to be built on its core values, the SSN returns to its original social insurance inspiration, or diverts towards a more private-based system will mostly depend on current decisions. We are approaching another landmark reform, which would not only affect the principle of universalism, but the unity of the country as a whole.
This report shows how the history of the health-care system has been characterised by a pattern of innovation and initiative, often leading to a crisis of spiralling costs and difficulties, followed by cost-containment measures and reorganisation. We describe how the tenuous balance of centralised versus regional and local control has shifted over time to create not one but, arguably, 20 different health-care systems in Italy, exacerbating differences between the north and south that have plagued the nation since before unification in 1861. Faced with a rapidly...