On Italian Health System Reform
Three works — a technical manuscript, an operational policy paper, and a ministerial policy brief — published between March and April 2026, articulate a structural reform proposal for the Italian Servizio Sanitario Nazionale (SSN). They share a single starting observation: the SSN combines excellent average clinical outcomes with rapidly deteriorating equitable access. In 2024, ISTAT data indicate that approximately 9.9% of the Italian population — around 5.8 million people — declined at least one medically necessary service, up from 5.5% in 2019. Out-of-pocket spending now represents around 22% of total health expenditure, well above the EU-15 average of 15%.
The problem is not solely under-financing, although under-financing is real. It is structural incoherence across an opaque four-pathway access architecture, an ambiguous public-private status for hospital physicians, and one of the most punitive medico-legal climates in Europe. These three works develop a coherent proposal — three structural decisions, four operational pillars — grounded in comparative evidence from high-performing systems, particularly the Netherlands and Canada, and informed by the author's direct clinical experience in both traditions.
The works
Rethinking the Italian Health System: Three Structural Decisions to Overcome the Four-Pathway Paradox
Technical manuscript · March 2026 · English
The anchor work of the programme. Develops the full architecture: the four-pathway paradox; physician status reform; a Safe Harbor medico-legal framework; and a national performance governance dashboard with digital and AI integration. Comparative analysis spans the Netherlands, Canada, and five European peers (France, Belgium, Germany, Switzerland, the Netherlands). Modelled scenarios — conservative, central, optimistic — suggest that coherent implementation could reduce foregone care from 9.9% toward approximately 5% within five years, while releasing €6–9 billion cumulatively from defensive and inappropriate expenditure.
Read the extended abstract and download the manuscript →
General Medicine as the Structural Pivot of the SSN
Policy position paper · April 2026 · Italian
Develops the territorial pillar of the technical manuscript at operational level. Proposes Integrated Primary Care Units (Unità di Cure Primarie Integrate, UCPi) as mandatory aggregations of 8–15 family physicians with family nurses, first-level diagnostics, scheduled specialist consultants, blended payment, binding gatekeeping for non-urgent specialist care, and measurable accountability on outcomes, patient experience, and appropriateness. The paper directly addresses the false dilemma between maintaining the existing convenzione status and transitioning to public employment, and situates the proposal within DM 77/2022 and PNRR Mission 6.
Read the executive summary and download the policy paper → (in Italian)
Ministerial Policy Brief: Rethinking the Italian SSN
Policy brief · 2026 · Italian
A synthetic version for policymakers of the proposals developed in the technical manuscript. Identifies actions immediately implementable within the 2026–2030 window without new legislation, distinguishing Phase 0 interventions (implementable through Law 107/2024) from medium-term reforms requiring parliamentary passage.
Download the policy brief (forthcoming)
Author's note
Claudio S. Cinà, MD, FRCSC, MSc, is a vascular surgeon with clinical and academic experience in Italy, Canada, the Netherlands, and the United States. The works presented here reflect four decades of comparative observation and are offered as a contribution to public debate.
Conflicts of interest: None declared. Funding: None.
For updates on forthcoming work, contact the author via the Contact page.