Court of Auditors

Health spending eaten up by inflation and 22% borne by households: sustainability challenge calls for sprint on Pnrr, more services and efficiency

In the Report to Parliament on the management of regional health systems, the certification of the nominal growth of expenditure, but also the snapshot of a system still in the post-Covid adjustment phase and burdened with territorial disparities that risk undermining the resilience of the system

by Barbara Gobbi

19 January 2026

4' min read

Translated by AI

Versione italiana

4' min read

Translated by AI

Versione italiana

In the three-year period from 2022 to 2024, public healthcare expenditure will grow steadily in nominal terms, but inflation will reduce real growth to just over 1 per cent, in a context of substantial stability in relation to GDP. Together with "structural rigidities" and "strong territorial inhomogeneities" on the one hand, and - on the other - the need to "accelerate Pnrr investments" that are marking time especially on the front of care closer to citizens with houses and community hospitals still largely to be built, this is the figure of the Corte dei Conti's Report to Parliament on the management of regional health services, for the 2023-2024 financial years.

The accounting magistrates therefore describe a post-pandemic National Health System 'still marked by strong territorial inhomogeneities and managerial criticalities, albeit on the way to a consolidation phase'. And whose future 'will depend on the ability to transform the nominal increase in expenditure into an actual improvement in services, strengthening territorial equity, digitalisation, proximity and sustainability'.

Expenditure data

From the Report approved by the Autonomies Section (Resolution no. 21/SEZAUT/FRG/2025), it emerges the increase from €131.3 to €138.3 billion in public health expenditure for the three-year period 2022-2024, with a growth of 4.9% over 2023 (5.4% over 2022) and the maintenance of a stable incidence on GDP (6.3-6.4%, against a European average of 6.9%). The increase "is driven by expenditure items related to personnel (+5.6%) and intermediate consumption (+7.5%)", but "reduced to a real increase of just over 1% due to inflation, highlighting an expenditure dynamic that is more defensive than expansive".

As in previous years, Italy's public healthcare expenditure in 2024 is significantly lower than the average of its European partners, both in per capita value and as a percentage of GDP. The level of Italian expenditure "is in fact conditioned by more stringent public finance constraints, given the large size of the debt", the Court further notes.

'The general trend,' is the observation, 'is one of stabilising post-pandemic funding, with the risk of implementing a healthcare spending model aimed at preserving the existing, rather than enhancing capacity and services'.

22% borne by households

Private expenditure and territorial gaps weaken equity of access and universality of service. In 2024, total healthcare expenditure was 185 billion, 74% of which was borne by the public administration and compulsory insurance, 22% by households, and 3% by voluntary schemes, "with a growth in the share referring to the private component that places the latter among the highest in comparison with the European average".

According to the Report, 'significant inequalities persist in the provision of the Essential Levels of Care (LEA) and a clear North-South misalignment. The Regions with a recovery plan (Calabria, Molise, Sicily, Campania, Lazio, Abruzzo, Apulia) continue to show structural difficulties despite some improvements in their accounts. The increase in inter-regional health mobility also marks gaps in the attractiveness and capacity to provide services.

Pillar health under pressure

According to Mef estimates - the Court further notes - healthcare expenditure will grow to 155.6 billion euro in 2028 with an average rate of increase of 3.7% per year. The incidence on GDP will remain stable (6.3%-6.4%), but sustainability depends on the containment of social security spending, which absorbs 68% of welfare spending, and on demographic trends. Spending on social protection (606.7 billion, 27.6% of GDP) shows a qualitative recomposition: emergency interventions are decreasing and structural funds are increasing (mental health, disability, youth). In short, Italian welfare 'is entering a phase of readjustment, with healthcare still a central pillar but under pressure'. Hence the main challenges of allocative efficiency and spending quality.

Pnrr late

On the investment front, the National Recovery and Resilience Plan (NRP) of Mission 6 Health, in which EUR 15.6 billion are planned to strengthen proximity, digitalisation and health infrastructure, 41% of the objectives were completed at the end of 2024, with the remaining 59% to be completed in the two-year period 2025-2026. The proximity network (with 1,038 Community Homes and 307 Community Hospitals planned) represents the strategic axis for the new National Health Service, but the monitoring showed delays in starting work and difficulties in recruiting staff, with shortages of health and technical profiles that could limit the full operativeness of the new facilities.
While the activated projects indicate 'good practices of sociomedical integration', the full operativeness of the proximity network 'will depend on implementation times and coverage of health and para-health personnel'.

Pharmaceuticals: extra spending ceiling

On the pharmaceutical side, overall expenditure 2024 has exceeded the planned ceiling of 15.3% of the Fsn. The introduction of the new expenditure ceilings and the payback mechanism guarantee - the Court of Auditors notes - a financial balance that presents, however, considerable margins of uncertainty linked to disputes with companies. The use of generics and biosimilars is growing.

The personal node

On the personnel side, there is significant recourse to flexible contracts and, in some regions, to so-called 'tokenists', an institution that entails higher costs and requires constant monitoring. In general, the shortage of public resources is reflected in the difficulty of recruiting and retaining staff.

The Court's recipe

The Court recalled the need to strengthen governance, accelerate investments, stabilise personnel, and correct the gaps between regions. The future of the NHS will depend, in fact, on the ability to transform resources into qualitatively better services, increasing management efficiency and strengthening territorial equity.