The Italian National Healthcare Service Reforms Trajectory

The Italian National Healthcare Service (INHS) has been since the 90s’ an extraordinary laboratory of innovation in governance and public management practices. Its trajectories of change, though turbulent as expected from a complex public sector, highlight extremely interesting take home lessons for those interested in understanding why and how a whole public system has evolved from traditional administrative logics into more managerial dynamics. In this light, the chapter analyses the evolution, the major reforms, and the challenges faced by the INHS during these almost five decades. The was established in 1978 to extend coverage to all Italians as a fundamental citizenship right. The wave of the New Public Management has led healthcare organisations to corporatisation and the introduction of managerialism. The decentralization from the national government to the 21 Italian regions has undergone periods of acceleration and attempts to stop it. Over the years, the dream of universalism has been challenged by several issues such as the continuous financial imbalance, the divide between northern and southern regions, and the slowdown of public financing. Several have been reforms adopted to regain financial sustainability and half of the regional healthcare services underwent a financial recovery programme. To promote accountability and focus on value creation, several reforms were introduced: clinical governance and evidence-based medicine; a catalogue of Essential Levels of Care; the implementation of new performance management systems for monitoring the outcomes of the INHS (National Outcomes Programme); significant organizational transformations and innovations. As a result, the INHS is today a high performer public sector, one that navigated the storms of COVID with great resilience and effectiveness and for many reasons a benchmark worldwide given its top health performances, high productivity and low and efficient level of expenditures.