The analysis

Differentiated autonomy in healthcare: a ‘reform in the dark’ that puts fairness at risk

Citizens face a fragmentation of rights amid a “deeply uncertain” situation regarding essential healthcare: Salutequità rejects the draft agreements between the Government and Liguria, Lombardy, Piedmont and Veneto

by Health Editorial Team

12 June 2026

5' min read

Translated by AI

Versione italiana

5' min read

Translated by AI

Versione italiana

“At present, the necessary and sufficient conditions are lacking to enable progress to be made on the approval process for the draft preliminary agreements on the granting of further forms and specific conditions of autonomy in the area of ‘health protection and public finance coordination’.” Tonino Aceti, president of Salutequità, an ‘Italian think tank’ dedicated to analysing trends and the implementation of health and social policies and to their innovation, with particular regard to the principle of equity, presented the analysis during the hearing before the Constitutional Affairs Committee of the Chamber of Deputies on the draft preliminary agreements between the Government of the Italian Republic and the Regions of Liguria, Lombardy, Piedmont and Veneto, for the granting of further forms and specific conditions of autonomy.

Too many uncertainties

Aceti explained that the picture painted by the agreements “is deeply uncertain with regard to the current LEAs and LEAs due to the cumbersome and slow nature of the update mechanism, the Lazio Regional Administrative Court’s annulment of the Tariff Decree, and the absence of a new decree, the absence of real costs and standard requirements, the current system for the distribution and allocation of resources among the Regions, which is unfair, and the inadequacy of the system for verifying and monitoring the LEAs – that is, all those aspects underpinning the rationale for the attribution of differentiated autonomy”.

Doubts about the “consequences”

Furthermore, according to Salutequità, the lack of an independent assessment of the impact of the increased autonomy granted to the four regions (Liguria, Lombardy, Piedmont and Veneto) that requested it – specifically regarding its neutrality in terms of its effects on the State and the other regions that did not request differentiated autonomy – in economic and financial terms and therefore on their budgetary balance, on the mobility of citizens, healthcare professionals and service providers, on ensuring equitable access to care throughout the country and on the uniform respect for patients’ rights, renders the entire operation a ‘reform in the dark’.

No independent assessment has been carried out

The Association’s position stems from the observation that there is a lack of independent assessment, based on objective data and analysis, regarding the impact that greater autonomy for the four regions might have not only within those regions themselves, but also on the State and on the other regions that have not requested differentiated autonomy, with consequences for the sustainability of regional health services, the principles of equity and solidarity within the NHS, and on the unity of the Republic, creating the risk of a competitive form of asymmetric regionalism, rather than one based on solidarity and cooperation, particularly in light of the absence of equalisation measures, starting with the implementation of the Equalisation Fund.

No detailed analysis has been carried out of the potential economic and financial implications, nor of the implications for the mobility of patients and healthcare professionals, nor, indeed, of the consequences for equitable access to care and the consistent protection of patients’ rights throughout the country.

“Proceeding without these assessments,” Aceti stresses, “means running the risk of a reform whose actual effects are neither known nor manageable.”

The Lep and Lea nodes

Another critical issue concerns the definition of Essential Performance Levels (EPLs) and Essential Levels of Care (ELCs). ‘The current LEAs, which date back to 2017,’ explains Aceti, ‘are now outdated and no longer meet the current needs of the population, nor are they in line with epidemiological and technological developments. To further complicate matters, recent rulings by the Lazio Regional Administrative Court have left the NHS in a state of profound uncertainty regarding the rights that citizens can actually claim. The government should issue a new decree, but the process appears complex and the timeline uncertain, exacerbating the regulatory uncertainty.”

Standard costs and requirements

The issue of costs and standard requirements remains an unresolved problem. Currently, the determination of these parameters is based almost exclusively on historical data and political negotiations, without an objective methodology that takes into account the real needs of the population, technological innovation, health poverty or the epidemiological characteristics of the regions. Istat has also highlighted how the resource allocation system is not proportional to needs, for example in the case of multiple chronic conditions, where no correlation is observed between funding and the prevalence of chronic diseases.

According to Salutequità, when it comes to guaranteeing Essential Levels of Care (LEA), the New Guarantee System (NSG) represents a step forward compared to the past, but it remains too limited. The indicators used are few in number and do not cover fundamental aspects such as healthcare staff, waiting times in A&E, and access to technological innovation. The most recent data show a patchy picture across the regions, with eight of them found to be non-compliant, including Liguria, one of those seeking differentiated autonomy.

“This situation,” says Aceti, “calls into question the possibility of ensuring uniform and equitable access to healthcare services throughout the country, undermining the principles of equality and unity of the Republic.”

Risk of resource depletion

According to Salutequità, provisions that would allow autonomous regions to set different reimbursement and remuneration rates, to allocate additional resources to staff or to expand services, and to reallocate savings to other areas of healthcare spending risk increasing the competitiveness of the strongest regional healthcare services. In the absence of equalisation measures, this could lead to a significant drain of patients, staff and resources from the weaker regions, exacerbating imbalances in terms of both the budget and the quality and quantity of healthcare provision.

Furthermore, there is a lack of monitoring and control mechanisms to assess the effects of the establishment of supplementary health funds and the new methods of resource management. No specific tools are provided for assessing the impact of these innovations on the equity, quality and safety of public healthcare provision. The composition of the Joint State-Region Commission should also be reviewed, including external and independent members to avoid the risk of self-referentiality.

Frame too fragile

“The duration and effectiveness of these agreements,” adds Aceti, “cannot be made contingent solely on maintaining economic and financial stability and ensuring the proper provision of Essential Levels of Care (LEA) in the regions that request them; they must also guarantee that there are no adverse effects on the State or on other regions. It is necessary to establish independent monitoring and verification systems that can assess, in a transparent and objective manner, the impact of the reform on all parties involved.”

Salutequità therefore believes that the current regulatory and operational framework is too uncertain and fragile to allow for progress on the draft agreements on differentiated autonomy in healthcare. The absence of independent assessments, the lack of objective criteria for defining costs and requirements, the inadequacy of monitoring and control systems, and the risk of exacerbating regional inequalities represent insurmountable challenges.

“Proceeding under these conditions,” concludes Aceti, “would jeopardise the principles of fairness, solidarity and unity that underpin the National Health Service, exposing citizens to a dangerous fragmentation of their rights and access to care.”