Harsh judgements reflect higher expectations

In the face of a particularly high demand for public protection, there is a growing perception in Italy of a fragmented and uneven system. This produces high expectations and, consequently, harsher judgements.

The first element that emerges from the international study carried out by the Noto Sondaggi Institute for Il Sole 24 Ore is the perceived fragmentation of Italy's public offer. Unlike in France, Germany, Spain and the United Kingdom, a significant proportion of citizens prefer to seek care in a different region from their region of residence. It is a structural, not an episodic phenomenon, reflecting the different organisational capacity and perceived quality between territories. Internal health mobility on the one hand testifies to freedom of choice and the existence of poles of excellence, on the other hand it signals an asymmetry in access and service standards. In the other major European nations analysed, recourse to internal travel for health reasons appears less marked, a sign of greater territorial homogeneity or of less regionalised organisational models. In Italia, on the other hand, decentralisation has produced regional systems perceived as differing in terms of efficiency, waiting times and quality of services.

Another aspect concerns the overall perception of public health. Italians' judgement appears more critical than in other countries. However, this greater severity should be read in the light of a structural fact: the national health service represents for the vast majority of citizensthe primary point of reference, not a residual one. In systems whereprivate insurance coverage is more widespread, such as in the UK or Germany, the pressure on the public component is more distributed and demand is more frequently channelled towards insurance or supplementary solutions. As a result, expectations of the public service in Italia are particularly high: if almost everyone turns to it, almost everyone measures its limits and potential.

The role of contracted healthcare must also be considered. In Italia, accredited facilities represent an essential component and functional extension of the public offer. Recourse to the 'private' paid for by the 'public' makes it possible to expand the capacity for response, reducethe waiting times and intercept a demand that would otherwise weigh entirely on the state structures. In other European contexts, the distinction between public and private is sharper and access to the private sector is mainly through insurance channels.

Taken together, these three factors - regional fragmentation, high public demand and the centrality of the contracted sector - outline a complex system. And the most critical perception does not only point to a performance problem, but tells of a country that continues to consider public healthcare a fundamental right.