Equity in the delivery and financing of health care and the SARS-COV-2 pandemic in Italy: where next?

SUMMARY Introduction: the Italian National Health Service (SSN-ServizioSanitario Nazionale) is characterised by growing socioeconomic inequalities in health care use and financing. Over the years, these have increasingly translated into tangible violations of the equity principle, which characterises the SSN, based on the idea that the public health system, according to the Constitutional dictation (art.3) should guarantee equal access to care for citizens based on healthcare needs regardless of their ability to pay. Objectives: to discuss the main Italian evidence available concerning income-related equity in the use (horizontal) and the financing (vertical) of healthcare services from a health economics perspective; to describe the main challenges posed by the SARS-COV-2 pandemic. Methods: the main evidence for Italy from the economic literature on the measurement of both horizontal and vertical equity is discussed and recent trends in healthcare expenditure are reported before and during the SARS-COV-2 pandemic. Results: before the outbreak of the pandemic in Italy, there were equity problems both in the use of services (horizontal) and in financing (vertical). Pre-existing socio-economic inequalities between individuals are increasing as a consequence of the economic crisis triggered by the pandemic. On the one hand, public health expenditure increased to counteract the consequences of the pandemic and, after years of cost containment policies, there has been a general awareness by the public decision-maker of the importance of public investment in health. The financing, on the other hand, does not seem to have altered its composition and at the moment no specific additional sources have been introduced. Conclusions: the economic crisis triggered by the pandemic is likely to increase socio-economic inequalities and to negatively affect the equity of the public healthcare system. Despite remarkable increases in public health expenditure introduced during the pandemic, the interregional structural gaps remain, which are sources of inequality and inequity. There is the need to define the criteria for the allocation of the increased public funding, which should be based on equity and not only on efficiency and appropriateness.