• Recent Eurobarometer surveys show that, in 2024, health is the second priority for European citizens. Health is even the main economic policy issue in a relatively large group of countries, such as France, Greece, Hungary, Ireland, Italy, Slovakia, Slovenia, Spain and Portugal.
• Yet only a few years earlier, in 2019, health (and healthcare) was excluded from the top ten priority issues for economic policy, except for a vague link to food safety and the need to protect consumers. The Covid-19 pandemic, which emerged in Wuhan, China, at the end of 2019, completely reversed the perspective, changed the perspective with which to look at healthcare: from healthcare only as a 'cost on which to save' to healthcare also as a 'social investment'.
• If we go back to the Covid-19 debate, especially in the first part of the pandemic, in 2020, when the effects on health were most pronounced, one strand of thought attributed the responsibility for the difficult situation we went through to the austerity of the years following the double international financial crisis of sub-prime mortgages and sovereign debts. Another strand of thought has instead taken it out on the governance of health systems, particularly in our country, attributing the harmful consequences of the pandemic to excessive regionalism. However, both positions are guilty of a simplistic approach.
• This issue of the Rivista di Politica Economica attempts to shed light on some of the many issues that need to be addressed for a serious debate on the subject of healthcare; and it tries to do so objectively starting from the numbers and evidence we have on the sector today. There are still two issues animating the current debate. The first concerns the volume of resources allocated to the sector. The second concerns regionalism, in particular the project to increase the spaces and forms of autonomy provided for in Article 116 of the Constitution under the umbrella of 'asymmetrical' or 'differentiated' federalism.
• In the first part of the volume, dedicated to the evolution of the sector and the major organisational issues, we address the topics of health expenditure, governance and the two major components of a health system in the production of services, the hospital sector and the territorial services sector. In the second part, we present a series of insights into the prospects for healthcare systems, in relation to demographic, skills and market developments.

• One of the sectors with the greatest impact on government and household expenditure is healthcare. Over the years, public spending restraint regulations and pandemic events have reshaped the levels and structure of healthcare spending.
• This work aims to provide an informative picture of the country's health expenditure through the measurement of financial flows linked to the consumption of health goods and services. The objective is to represent the health system from the expenditure side through the analytical reading of the data provided by the "System of Health Accounts" (ISTAT) which, together with other statistical information, represents a tool for monitoring and evaluating health services in the period 2012-2023.
• The focus of the analysis is on public health expenditure, expenditure directly supported by households and expenditure financed by companies for workplace health promotion. Furthermore, a description of the size of health expenditure and its distribution by care function in the EU countries is provided.

JEL Classification: I10, I11, I15, I18
Keywords: health expenditure, care functions, providers, public expenditure, business expenditure, out-of-pocket expenditure .

• The healthcare systems of the EU member states are very different in many respects: from the relative roles of the public and private sectors in financing insurance schemes, to the organisation of service provision, to the management of hospital versus community medicine. The differences reflect decisions enshrined in national laws of the central government of individual countries, which also reflect cultural approaches to the role of the welfare state more broadly.
• In all countries, most of the functions related to healthcare systems are shared between different levels of government. For example, in Italy, the structure of supply is influenced by national legislation (which sets the standards for beds per inhabitants and the structural characteristics of hospitals) and by regional legislation (which determines the organisational structure of the network of services within the region within the spaces of autonomy left by the national norm). These examples show the difficulties of defining the degree of autonomy for different functions. Similar considerations apply to functions that are shared between countries and the European Union, such as the marketing authorisation of medicines.
• Classification exercises of health systems make clear the difficulties in standardising functions and identifying common structures. In regulatory terms, the allocation of functions to different levels of government should be based on the consideration of economies of scale, potential spillovers and heterogeneous local preferences.

• Europe's social systems have long been challenged by the increasing prevalence of chronic diseases, a phenomenon with multifactorial origins influenced by the demographic trend of ageing, increasing survival rates, improving economic and social conditions and the availability of new, high-cost therapies.
• In Italy, six years after the first National Plan for Chronicity (PNC), approved in 2016, the impact of the pandemic and the availability of new resources from the Next Generation EU programme have stimulated new energies to refound the foundations of the PNC by endowing it with a 'strengthened' model of territorial care that is at the heart of Ministerial Decree 77/2022.
• After a brief analysis of the new territorial care designed by Ministerial Decree 77, some problems of the Italian model of general medicine are discussed and some interventions are proposed to enhance the role of primary care and to enable it to face future challenges in the best possible way. Some proposals envisage less divisive interventions, such as the reform of the training pathway or a better weighting of the list of patients, others imply more radical choices, such as a greater territorialisation of primary care or the creation of a third level of family medicine aimed at the older population.

• The organisation of healthcare provision, particularly hospital care, has undergone profound change in recent decades, in Italy as in many other countries. In particular, our National Health Service (SSN), while reaffirming the basic principle of universal coverage, has been affected by various reforms at the 'macro' level, aimed at increasing the degree of autonomy and fiscal responsibility of regional governments, and at the 'micro' level, introducing elements typical of the organisational models of 'quasi-markets', through the separation of funders from providers of hospital services (vertical de-integration) and the conferral of management autonomy on public hospitals. This process contributed to the creation of several regional healthcare systems, each with its own characteristics in terms of the degree of vertical de-integration and the role attributed to private hospitals.
• The article examines the main reforms of the NHS, focusing the analysis on the provision of hospital services, which alone accounts for almost 50% of the total public health expenditure. The contribution aims to give a key to understanding these reforms through a theoretical-institutional framework, aimed at characterising their potential effects on hospital supply. An attempt is also made to provide an assessment of the current performance of the NHS, presenting some regional indicators concerning health outcomes, appropriateness and quality of the hospital services provided, which are then used to briefly discuss the possible links between the way the reforms are implemented by the various regions and the performance of the respective healthcare systems. The analysis does not seem to reveal a clear correlation between the adoption of a certain organisational model and the observed results. This evidence suggests that the quality of the political and market institutions responsible for the governance of the regional health care systems plays a fundamental role in determining the achievable improvements in terms of efficiency and equity.

JEL Classification: H75, I11, I18, L33, R10.
Keywords: NHS, hospital services, quasi-markets, regional models, performance indicators.

• The sociomedical sector has long represented a significant employment pool: in 2021, at European level, one in ten people worked in the sector (10.7% of total employment), Italy was just below the average (8%).
• With an often different narrative compared to countries such as France and Germany, Italy lacks nurses more than doctors. This different skill mix could be a symptom of the country's delay with respect to the transition to a healthcare system oriented towards territorial care and could, in fact, impede this transition.
• The National Health Service companies and institutions continue to be the largest employer in the sector, employing more than 600,000 employees, 30% of those employed in the sector according to OECD data.
• Mismatch phenomena are also observed in the labour market of social and health services, linked to an excess of demand over supply of nurses and doctors specialised in certain disciplines such as emergency and urgent care, anaesthesia and resuscitation or territorial medicine.
• In addition to salaries, which are not dissimilar to those in other countries when considered in relation to average salaries, the possibilities of salary supplementation offered by the liberal professions and the risks for medical liability may help to explain the mismatch.

• Scientific research shows that managerial practices have a significant influence on the performance of hospitals and that an adequate supply of human capital with managerial skills represents an opportunity for increasing productivity. Given the enormous pressure that health systems are under, the development of management skills could be a complementary approach to cope with health care demands, in addition to strategies focused on increasing clinical-medical inputs.
• In Italy, the healthcare reforms have created the conditions for the regionalisation and corporatisation of the healthcare system and for the emergence of apex figures in charge of its management. For them, education and training in the managerial sphere represent essential requirements, consistent with the scientific evidence that emphasises their fundamental contribution to the achievement of adequate clinical outcomes and the economic-financial equilibrium of the healthcare agencies.
• The available evidence on the management training of general managers is fragmented and reflects the fragmentation of the NHS into multiple and distinct regional healthcare models. Training courses tailored to regional realities may be effective in the pursuit of internal strategic objectives or, on the contrary, ineffective.

• Apart from the emergency phase of the Covid-19 pandemic, private healthcare expenditure in Italy has grown steadily over the last three decades due to structural factors and public finance constraints. Out-of-pocket expenditure is the main component of private healthcare expenditure (89% in 2022). A smaller share is intermediated by health insurance or covered directly by companies, health insurance funds and other private funds. The intermediated component has recorded an increase in its weight over time, a dynamic that is also due to the tax breaks provided by the legislation. For Italy, there are no complete and systematically collected public data on the types and characteristics of the various forms of supplementary health insurance. The limited and fragmentary public information available reveals a particularly large percentage of the population covered by private insurance and funds (over 30%), even if the amounts insured and covered in the Italian case are relatively small; the coverage offered is mainly duplicative (or substitutive) for NHS services, but about one third of the intermediated private health expenditure is of a supplementary nature, that is, it refers to services supplementary to the Essential Levels of Care.
• Based on the micro sample data of the SHARE survey, which also collects information on the socio-economic status, health and access to care of individuals over 50 years of age in Europe, it is possible to describe the differences in socio-demographic characteristics between insured and uninsured households. Our descriptive analysis shows that households with voluntary private health insurance have higher levels of education and income and are characterised by a higher probability that at least one of their members is employed.
• The empirical analysis based on a multiple linear regression model shows that the partial correlation between voluntary private health insurance and out-of-pocket expenditure is either positive or statistically non-significant in the European countries analysed, confirming empirical evidence from previous studies.