From Care to Prevention: The Dual Pillar of the New Italian National Health Service (SSN)

(Originally published in Artemisia Magazine, No. 25, November 2025)

By Arch. Mariastella Giorlandino, President of UAP and Fondazione Artemisia;
Dr. Paolo Poletti, Lecturer in Information Security Management at Link Campus University of Rome; Senior Advisor, Artemisia Lab and UAP

UAP (National Union of Outpatient Clinics and Multispecialty Clinics, Healthcare Entities and Private Hospitals) is the leading Italian association representing private healthcare providers.

Why a change of pace is needed — now.

“Primary prevention is perhaps the main pivot on which to focus our health policies: without it, the system will very soon become unsustainable.”

This reflection by Sergio Harari, published in Corriere della Sera on 25 October 2025, clearly captures today’s reality: Italy has entered a demographic phase that makes a healthcare model based predominantly on treatment no longer sustainable.

With more than one fifth of the population now over the age of 65 and a steady increase in chronic diseases, the Italian National Health Service (SSN) stands at a crossroads. The “medicine of disease” — centred on hospitalisations, volume-based services and ever-increasing costs — can no longer withstand the impact of social and economic change.

What is required is a cultural and strategic shift: moving from a system that intervenes after disease onset to one that builds health upstream, investing in prevention, early diagnosis, healthy lifestyles and territorial care pathways. This transition also requires redefining the relationship between public and private healthcare, based on complementarity rather than competition.

An SSN under pressure

Lengthening waiting lists, tariffs that fail to cover real costs, healthcare inflation eroding both resources and public trust: the SSN is under strain. Over the past decade, public healthcare expenditure has not grown in proportion to needs, while citizens’ out-of-pocket spending has now exceeded 25% of total healthcare costs. Regional disparities in access to care remain stark, with life expectancy gaps of up to five years between Northern and Southern Italy.

Yet universalism remains a non-negotiable principle. Italy’s Constitutional Court has repeatedly affirmed that healthcare is a constitutionally necessary expenditure: not merely a budget line, but a duty of the State towards its citizens.

In this context, prevention becomes the only viable path to preserving universality without sacrificing sustainability. Every euro invested in prevention saves three euros in treatment costs — but only if prevention is made structural, not episodic.

From a care-based model to a prevention-based model

A prevention-centred SSN is not a utopian vision, but an operational necessity. It means networking territorial healthcare, enhancing the role of general practitioners, supporting telemedicine and hospital-at-home programmes. It means investing in screening and vaccination campaigns, health education programmes, and public policies that promote healthy lifestyles.

Preventive healthcare does not wait for the patient: it accompanies them. It anticipates diagnosis, monitors conditions, educates, and integrates clinical data with everyday behaviours. Achieving this requires a “dual-pillar” reform: public and private sectors moving together under shared rules, to ensure timeliness, quality and safety.

Tariffs and the new nomenclature: securing the “price” of health

Revising the tariff nomenclature has become an urgent priority that can no longer be postponed. After years of delays, and following the Lazio Regional Administrative Court ruling No. 16370/2025 annulling the previous ministerial decree, the Government has finally allocated — through Article 67 of the 2026 Budget Bill — the resources needed to launch a comprehensive reform of the healthcare reimbursement system.

This represents a concrete step towards a fair tariff balance that values quality and ensures the sustainability of the SSN for both public providers and accredited private facilities.

However, as UAP has already stressed to the competent Ministers, the 365-day deadline set by the Court must be considered a maximum limit, not a target.

With resources already available, action must be immediate: every delay exacerbates the sustainability crisis faced by thousands of healthcare facilities and, by extension, the quality of care provided to citizens.

The objective must be to define realistic, transparent tariffs grounded in uniform technical criteria, based on:

• updated and representative surveys of real service costs, both public and private;
• the use of established economic analysis models, such as Activity-Based Costing and full costing;
• careful assessment of regional tariff schedules used as benchmarks;
• detailed and documented justification of policy choices.

A permanent technical committee involving the Ministry of Economy and Finance, the Ministry of Health, the Regions and professional associations — based on certified cost accounting and biennial reviews indexed to healthcare inflation — would transform tariff revision into a continuous and verifiable process.

Finally, an employment safeguard clause linking tariff revisions to the preservation of staffing levels and collective labour contracts would protect service quality and employment stability.

Only with clear rules, objective data and immediate implementation can the new nomenclature become the engine of a fairer, more sustainable and citizen-centred healthcare system.

Stable and indexed funding

Raising the National Health Fund to 7% of GDP is necessary, but not sufficient. An automatic indexation mechanism tied to the healthcare deflator is also required, to prevent inflation in medical devices and pharmaceuticals from eroding nominal funding increases.

Waiting lists: governance, single agenda, SSN vouchers

Reducing waiting times requires integrated management of the public–private dual pillar already envisaged by Law No. 833/1978. A single, interoperable scheduling agenda would allow full use of the productive capacity of both networks. When maximum waiting time thresholds are exceeded, an SSN voucher would enable citizens to access accredited private providers at public tariffs, ensuring continuity and timeliness of care.

In summary:

• Interoperable single agenda: Regional booking systems draw from a unified calendar (public and accredited private facilities). Outcome: full use of capacity; reduced waiting times without additional costs.
• SSN voucher: when thresholds are exceeded, citizens receive a voucher redeemable at accredited private providers at SSN tariffs. Outcome: protection of timely access; reduced migration to private intramoenia (in the Italian healthcare system, “intramoenia” refers to the legally regulated private medical practice performed by public-sector physicians within public hospital facilities, outside standard public service hours, with direct payment by patients) or other regions.

A tariff equilibrium coefficient updated every two years would prevent distortions and ensure sustainability for both pillars of the system.

Digitalisation and cybersecurity: two sides of the same coin

Prevention also depends on knowledge and data security. In the new digital healthcare ecosystem, protecting citizens’ health cannot be separated from protecting their health data. The expansion of the Electronic Health Record 2.0 and the forthcoming implementation of the European Health Data Space (EHDS) make a uniform, verifiable cybersecurity model indispensable.

The legal framework is now clear. Directive (EU) 2022/2555 (NIS2), transposed in Italy by Legislative Decree No. 138/2024, imposes specific cybersecurity and risk management obligations on providers of essential services, explicitly including public and private healthcare facilities.

The decree distinguishes between “essential” and “important” entities, including:

• healthcare and social care providers;
• operators managing large-scale clinical or health data;
• biomedical and pharmaceutical research entities with critical digital infrastructures.

In this context, cyber risk is no longer merely a technical issue, but a systemic public health risk.

Healthcare has long been among the sectors most targeted by cyberattacks: hospitals, local health authorities and diagnostic laboratories are high-value targets for criminal groups seeking sensitive data for ransom or strategic purposes related to pharmaceutical and biotechnological research.

In some cases, suspicions arise that certain hacking operations may involve borderline practices by chemical-pharmaceutical companies seeking to reduce epidemiological research costs through illicit access to stolen databases.

For this reason, the digital healthcare of the future must be built on “security by design”, with structured and verifiable measures.

UAP proposes an integrated model based on four operational pillars:

• a national 24/7 Healthcare SOC, established within the National Cybersecurity Agency and the Ministry of Health, to coordinate incident response and monitoring;
• mandatory adoption of the Health-ISA standard (healthcare profile of ISO/IEC 27001–27002) as a prerequisite for accreditation of public and private healthcare facilities;
• a national registry of connected medical devices, with centralised vulnerability management, regular software updates (patch management) and component verification (SBOM);
• continuous training for clinicians, technicians and administrators through certified “cyber hygiene” programmes to mitigate human risk, the primary attack vector.

Only under these conditions can “digital care” develop securely, ensuring continuity of care, public trust and protection of health data.

Digitalisation and cybersecurity are not parallel paths, but two sides of the same coin: modernising the SSN requires a robust security culture as an integral part of the right to health in the 21st century.

Value-Based Healthcare (VBHC): paying better for better care

In recent years, a new paradigm has emerged internationally in healthcare management: Value-Based Healthcare (VBHC).

The principle is simple yet transformative: what matters is not how many services are delivered, but how much patients’ health improves. Remuneration should be linked not to volumes, but to real health outcomes.

Originating in the United States through the work of Michael Porter (Harvard Business School), VBHC has spread across Europe as a tool to improve care quality, transparency and spending efficiency.

Applying this model means moving beyond fee-for-service reimbursement and building a system that rewards clinical value, measured through shared and verifiable indicators.

Value is defined as the ratio between health outcomes achieved and the resources used to achieve them.

Outcomes are assessed using standardised tools:

• PROMs (Patient-Reported Outcome Measures), capturing patient-perceived clinical and functional improvement;
• PREMs (Patient-Reported Experience Measures), assessing care experience from the patient’s perspective.

Starting in 2026, UAP proposes three national pilot projects — hip replacement, coronary angioplasty and cataract surgery — with a reimbursement model composed of 90% fixed and 10% variable, linked to PROMs and PREMs outcomes.

Results, publicly available from 2028, will allow citizens to compare provider quality, rewarding transparency and expertise.

In the long term, a value-oriented system reduces regional variability, improves average care quality and enhances resource efficiency. It reconciles equity, merit and sustainability: public healthcare remains universal, while recognising and incentivising excellence.

Healthcare SMEs and economic governance

The network of small and medium-sized accredited healthcare providers is a strategic asset. UAP proposes a CDP–EIB revolving fund to finance digitalisation, cybersecurity and energy efficiency, with public guarantees of up to 80%. In parallel, a “healthcare golden power” mechanism would protect Italian ownership of territorial healthcare networks, preventing excessive concentration that would undermine less profitable areas.

Governance must also be transparent. A national register of SSN administrative and financial directors and the publication of efficiency indicators in open data would strengthen civic oversight and meritocracy.

A “dual-pillar” reform for a universal and sustainable SSN

Healthcare reform can no longer be limited to correcting imbalances; it must rethink the very paradigm of public health. The public–private “dual pillar” is not a compromise, but a pragmatic model to address future challenges:

• the public sector as guarantor of rights, equity and strategic governance;
• accredited private providers as operational allies, integrators and innovators;
• prevention as the guiding thread of a system that seeks to remain universal, timely and sustainable.

Integrating these levers means moving from principles to operational mechanisms: sustainable tariffs, unified governance, cybersecurity by design, outcome-based evaluation, and protection of healthcare SMEs.

Only in this way can Italian healthcare face the future with confidence, transforming its tradition of excellence into a new health model founded not only on care, but on prevention as the infrastructure of life.