Italia put to the test by regional healthcare reform: how healthcare provision has been reshaped

‘Contesa’ is a word with a double meaning. It echoes the idea of a contest, a dispute in which arguments are openly weighed up; yet the Latin *contendere* also conveys the notion of striving together, the effort towards a shared goal. Over the twenty-five years since the adoption of Title V, healthcare has been both of these things: a battleground between the State and the Regions and, at the same time, a horizon towards which the Republic – to which, and not to the State, Article 32 entrusts its protection – is called upon to strive. It is between these two meanings that *La salute contesa* (Il pensiero scientifico editore, 2026) navigates; this book, in which we attempt to decipher what has happened to the National Health Service, was presented at a meeting at Palazzo Madama, in collaboration with the Roche Foundation.

For a long time, the explanation was sought solely in the division of powers, as if it were enough simply to shift the balance between Rome and the regions, until the pandemic revealed the limitations of this approach: there was no shortage of those with the power to decide; what was lacking, at times, was the ability to decide together. Although it has remained a matter of concurrent jurisdiction, the protection of public health has in fact been reshaped by a silent metamorphosis, consisting of court rulings, recovery plans, essential services that are updated with great difficulty, and budgetary constraints. Hence our argument: the effectiveness of the law depends less and less on who holds the powers and increasingly on the quality of the relationships between those who exercise them.

Health is therefore a matter of contention in the highest sense: not a battlefield, but a place where a range of entirely legitimate demands converge, such as universality and sustainability, autonomy and unity, innovation and equality of access to care. The dispute centres not on pathology but on physiology, and the Constitutional Court, rather than acting as an arbiter, has been its architect: it has made essential levels the cornerstone of substantive equality and has emphasised (judgement no. 275 of 2016) that it is the guarantee of inalienable rights that affects the budget, and not the other way round. This is confirmed, moreover, by healthcare mobility: seeking treatment elsewhere for a highly specialised procedure is a choice; being forced to do so for routine care is a form of inequality.

Hence our proposals. The first concerns loyal cooperation, which, when made rigid by the requirement for unanimous agreement, becomes a veto capable of paralysing decision-making: we therefore propose rules based on qualified majorities or balanced blocking minorities, not to weaken the Regions but to enable joint decision-making in a timely manner, as indicated, moreover, by Judgment No. 192 of 2024, which anchors autonomy to a genuine – not presumed – assessment of rights.

The second concerns administrative capacity: the training of senior management, interoperable data, and evaluation as a means of learning rather than control.