Unlike other healthcare systems in Europe, Italy’s Servizio Sanitario Nazionale (or SSN) operates on a regional rather than national level.

This means that, though they must abide by broad guidelines set by the health ministry, local health authorities (Aziende Sanitarie Locali, ASL) act independently, managing their own clinics and medical services, including the costs of individual procedures and pharmaceuticals.

This decentralised system has long been criticised by experts for creating imbalances in the level of care offered across the country, especially between north and south, with the EU Commission previously noting how “different fiscal capacities and health system efficiency levels” impacted “the ability of poorer or lower-performing regions to provide access to high-quality healthcare”.

And north-south disparities have indeed been flagged by multiple media reports over the years, including Il Sole 24 Ore’s yearly Health Index. 

But as a recently approved autonomy bill allowing regions to claim broader powers on key public services and retain more of their tax revenue threatens to further deepen healthcare imbalances, exactly how severe is Italy’s north-south healthcare divide? 

‘Essential Levels of Care’

First established in 2001, the Essential Levels of Care (or LEA) system is the health ministry’s primary method of evaluation of all the different regional health authorities. 

This assesses the essential services that “the National Healthcare System (SSN) is required to provide to all citizens,” regardless of the region they live in, and refers to three macro-areas – prevention, clinic care, and hospital care – giving each one a score from 0 to 100, with 60 being the passing grade.

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The 2023 LEA report showed marked differences between northern and central regions and their southern counterparts.

Barring Valle d’Aosta and the autonomous Bolzano province, all regions in the north and centre of the country achieved a passing grade in each of their three health macro-areas. By contrast, five out of eight southern regions, namely Molise, Campania, Calabria, Sicily and Sardinia, failed to reach the passing grade in at least one of the three macro-areas.

Scores were particularly low in Calabria, which stopped short of passing grade in all macro-areas, and Sardinia, which failed in two out of three areas.

In each of the three macro-areas, the highest scores were achieved by regions located in northern Italy, with the autonomous Trento province ranking first both in the prevention area (92.5) and in the hospital area (96.5), and Emilia-Romagna ranking first in the clinic area (96).

Overall performance ratings

Another popular way to assess regional healthcare systems is through the yearly performance index by Italy’s Centre for Applied Economic Research in Health (CREA), consisting of a panel of 104 healthcare experts. 

The index collates data on twenty markers, ranging from care efficiency, clinical outcomes, innovation, financial situation and patients’ satisfaction, producing an overall performance rating from 0 to 100.

The most recent report, published on July 1st, ranked regions into four different categories based on their performance levels. 

• Scores between 54 and 60: Veneto, Piedmont, autonomous province of Bolzano, and Tuscany
• Scores between 45 and 50: Friuli-Venezia Giulia, autonomous province of Trento, Emilia-Romagna, Liguria, Valle d’Aosta, Marche, and Lombardy
• Scores between 37 and 44: Sardinia, Campania, Lazio, Umbria, Abruzzo, and Puglia
• Scores under 35: Sicily, Molise, Basilicata and Calabria

Quite tellingly, no southern region figured in the top two categories, with the best-placed southern region being Sardinia, with a score of 44 (that’s 16 points lower than first-ranked Veneto).

Southern Italy’s Calabria was once again the worst-performing region, with a score of 26.

Patients forgoing care

The number of people forgoing medical care every year due to long wait times, difficulties in reaching the relevant healthcare facility or for economic reasons is also frequently used to evaluate regional healthcare systems.

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According to the most recent data published by Italy’s National Institute of Statistics, some 5.4 percent of Italian residents renounced seeking specialist consultations in 2021 – but figures varied greatly from region to region.

The percentage of residents who forwent specialist visits ranged from a minimum of 2.2 percent in the autonomous province of Bolzano to 8.3 percent in Sardinia. 

Besides Sardinia, Abruzzo (7.7 percent), Lazio (6.9), Umbria (6.7), Puglia (6.6), and Calabria (6.5) all fared particularly badly.