Gimbe analysis

Health, household spending at 41.3 billion and pure private booms with 7.2 billion (+ 137%)

Out-of-pocket expenditure is growing and the number of private entities providing health services and benefits is increasing: among the proposals are the revision of the Essential Levels of Care and the definition of a second pillar that is truly supplementary to the SSN

by Health Review

26 November 2025

5' min read

Translated by AI

Versione italiana

5' min read

Translated by AI

Versione italiana

In 2024, out-of-pocket healthcare expenditure in Italy will amount to EUR 41.3 billion, or 22.3% of total healthcare expenditure: a percentage that for 12 years has exceeded the 15% limit recommended by the WHO, a threshold beyond which equality and accessibility to care are at risk. In absolute terms, this expenditure has grown from 32.4 billion in 2012, remaining between 21.5% and 24.1% of total expenditure.

Giving the figures is the Gimbe Foundation: "With almost one euro out of every four of health expenditure disbursed by families," observes president Nino Cartabellotta, "today we are essentially faced with a 'mixed' health service without any government ever having explicitly provided for or declared it. Moreover, out-of-pocket spending is no longer a reliable indicator of the lack of public protection, because it is increasingly being stemmed by the impoverishment of families: waivers of healthcare services have risen from 4.1 mln in 2022 to 5.8 mln in 2024'.

Poverty physiological limit

In other words, they point out from Gimbe, private expenditure cannot grow more because in 2024, according to ISTAT, 5.7 million people lived below the absolute poverty line and 8.7 million below the relative poverty line. The composition of private spending can be deduced from the Health Card System: in 2023 (the most recent year available), the 43 billion in private healthcare spending goes for 12.1 billion to pharmacies, 10.6 billion to professionals - of which 5.8 billion to dentists and 2.6 billion to doctors -, 7.6 billion to private individuals accredited with the SSN, 7.2 billion to 'pure' private individuals, and 2.2 billion to the National Health Service as remuneration for the free profession. "These numbers," Cartabellotta observes, "say that the privatisation of spending is leading to a progressive exit of citizens from the perimeter of public protection, with the necessary services being purchased on the market.

The boom of the pure private

The other side of the coin in the analysis of health expenditure borne by citizens is the 'privatisation of production': this mainly involves, on the one hand, private facilities with agreements with the NHS, which provide services and benefits on behalf of the NHS and are reimbursed with public resources, and, on the other, the private sector without agreements with the NHS. And it is in this latter sector, made up of healthcare facilities, mainly for outpatient diagnostics, which provide services without being reimbursed by public expenditure, that the Gimbe Foundation records a real exploit: between 2016 and 2023, household expenditure increased by 137% from 3.05 billion to 7.23 billion, with an average increase of about 600 million per year.

Slow down private contracting

In the same period, household spending on the accredited private sector grew by only 45%; as a result," the Gimbe Foundation observes, "the clear gap between household spending on the 'pure' private sector and on the private sector with special agreements has practically disappeared, going from 2.2 billion in 2016 to just 390 million in 2023. "Among the privatisation phenomena," Cartabellotta comments, "the most worrying dynamic is therefore the speed of growth of the 'pure' private sector. In fact, while the public debate continues to focus on the role of the private contracted sector, whose incidence on healthcare spending has even decreased, the data document the exponential growth of out-of-pocket spending towards the private-private sector. Not finding timely answers in either the public or the accredited private sector, those who can pay look elsewhere and exit the perimeter of public protection. This circuit, together with intramoenia, represents the only loophole for citizens trapped on waiting lists'.

The other actors in the field

The intermediation of private health expenditure is entrusted to the so-called 'third-party payers', who populate - as Gimbe reminds us - a complex ecosystem made up of health funds, mutual funds, insurance companies, businesses, third-sector entities and other non-profit realities. In 2024, according to Istat-Sha data, the expenditure incurred by these entities reached 6.36 billion, with an increase of over 2 billion in the three-year post-pandemic period. 'It should be reiterated,' Cartabellotta explains, 'that supplementary health funds and corporate welfare are granted a tax exemption whose impact on public finance has never been made public, nor can it be calculated. But which is, indirectly, an instrument of hidden privatisation, given that it diverts public resources mainly to private subjects'.
In addition, the potential of integrative healthcare would be greatly reduced in the current context of crisis of the SSN. With almost 12 million members in 2023, the health funds have to reimburse an increasing number of services that public healthcare can no longer guarantee. And this imbalance undermines its sustainability: the more the SSN declines, the more the demand for reimbursements increases and the whole system struggles to cope. 'Integrative healthcare,' warns Cartabellotta, 'can only function if it integrates a strong public system. If instead it is called upon to replace its deficiencies, it risks sinking along with the SSN'.

There is also an increasing number of investment funds, insurance companies, banking groups and corporations that, stimulated by long-term trends such as an ageing population and increasing chronic illnesses, see healthcare as a highly profitable sector. These private players invest resources in their business plans as venture capital, either by acquiring company shares or by entering into public-private partnerships (PPPs) with health authorities, regions and other entities. "While the entry of private capital into healthcare cannot be criminalised," warns Cartabellotta, "without clear rules and rigorous governance, there is an increased risk of imbalance between the public objective of health protection and the entrepreneurial objective of the legitimate generation of profits. Particularly critical,' the Foundation continues, 'is the direct relationship between private investor and 'pure' private provider, which gives rise to that 'second track' that is totally disengaged from the SSN and intended exclusively for those who can pay directly or through insurance coverage.

Which integration

"In this scenario,' Cartabellotta comments, 'characterised by the progressive retreat of public healthcare and at the same time by an unregulated expansion of innumerable private entities that also pursue profit goals, talking about 'public-private integration' becomes anachronistic and outrageous with respect to Article 32 of the Constitution and the founding principles of the National Health Service. If safeguarding a public, fair and universalistic NHS is no longer a priority for our country, politicians should have the courage to say so openly to citizens and manage privatisation processes with rigour, instead of letting them run wild. Alternatively, publicly take responsibility for the 'ordinary maintenance' of a model that produces inequalities, impoverishes families, penalises the South and abandons the elderly and frail. Because it is there for all to see that the privatisation of the NHS, unplanned and unannounced and proportional to the weakening of the NHS, is turning rights into privileges'.

The proposals

From the Gimbe Foundation they reiterate that it is still possible to reverse the course. How? With a consistent and stable relaunch of public funding, a 'basket' of essential levels of care compatible with the amount of resources allocated, a 'second pillar' that is truly integrative with respect to the SSN and avoids diverting public funds towards private profits and fuelling consumerist drifts, a public-private relationship governed by clear public rules under the banner of real integration and not sterile competition. 'Only by intervening on these strategic axes,' Cartabellotta concludes, 'will it be possible to restore to the SSN the role that the Constitution assigns it: to guarantee to all people the right to health protection, regardless of income, place of residence, and socio-cultural conditions. Because in the face of illness we are all equal only on paper. But in everyday life there are unacceptable inequalities that a civilised country cannot accept'.