On 19 June 2024, the Italian Parliament approved the differentiated autonomy legislation for regions (Law n. 86 of 26 June 2024), as outlined in Article 116 of the Italian Constitution, paragraph 3. This law sets the principles and procedures for granting greater autonomy to regions that request it, covering 23 policy areas, including healthcare. According to the constitution, healthcare is a shared competency between the regions and the national government, but the new law would make it the exclusive jurisdiction of the regions. This means that the regions will have the exclusive power to legislate, subject only to the general limits imposed by the central government.
The new law establishes that the regions can only be granted greater autonomy after the “essential levels of performance” (livelli essenziali delle prestazioni, LEP in Italian) have been defined, covering essential areas such as education, public transport and social care that need to be guaranteed uniformly across the country. The government will have to establish the LEP within two years via legislative decree. The first Budget Law of the Meloni government, approved at the end of 2022, initiated the steering committee for the determination of the LEP. The new law includes mechanisms to monitor the economic impact of the autonomy agreements with regions, with a committee created to oversee each region’s assets and the human and financial resources it will need to exercise its autonomous functions in the various policy areas, in compliance with public financial objectives and to ensure balanced budgets.
Within healthcare there are already established services that the National Health Service must provide, known as Essential Levels of Care (Livelli essenziali di assistenza, LEAs) and which must be delivered by the regions. These are divided into three categories for the purposes of regional monitoring of care: prevention and public health, district (community) care and hospital care.
The law does not mandate automatic approval of regional requests for more autonomy, but establishes a detailed procedure. However, some critics argue that the law could exacerbate existing territorial inequalities (especially between the richer northern parts of the country and the poorer southern areas). Greater autonomy may worsen existing disparities in healthcare, life expectancy, and the mobility of patients between regions to seek care, potentially leading to a sustainability crisis in the better endowed northern regions and a weakening of the healthcare system in southern regions. For example, greater autonomy in personnel negotiations will cause healthcare professionals to migrate to (northern and central) regions that can offer better economic conditions, further depleting the human capital of in southern regions.
Reflecting on these new governance developments, the Bank of Italy (2023) has pointed out the risks of a highly differentiated institutional setup, such as increased coordination costs and weakened accountability. It also noted the need for national-level coordination on certain competencies, which are seen to be irreconcilable with the transfer of powers to individual regions, citing the fragmented management of the COVID-19 pandemic as an example. There is also a reported lack of clear criteria to verify a region’s readiness for greater autonomy. The law mentions that “the financial framework of the region” is considered, but the formula is deemed vague, non-binding and open to different interpretations.
These concerns are aligned with those expressed, among others, by the European Commission in its Country Recommendations for Italy in May 2023 (European Commission, 2023), stating: “Overall, the reform envisaged by the new framework law risks compromising the ability of public administrations to manage public spending, with a consequent possible negative impact on the quality of Italy's public finances and on regional disparities”.