22 May 2025 | This Focus analyses the state of progress of Mission 6, Health, of the National Recovery and Resilience Plan (NRRP). The analysis goes beyond the mere issue of formal compliance with the deadlines set for the achievement of the targets, focusing instead on the concrete likelihood of success of the endeavour to reorganise and strengthen the Italian National Health Service (INHS). Accordingly, in addition to considering the implementation status of investments on the basis of the most recent data available (official monitoring documents and the ReGiS platform), it assesses developments in terms of the effective, full and structural roll-out of the new services. Indeed, the strengthening of the INHS – which the pandemic emergency, by highlighting criticalities and shortcomings, has made unavoidable – has largely been entrusted to the NRRP.
NRRP funding for the Health Mission amounts to €15.63 billion, to which are added the resources of the National Complementary Investment Plan (NCIP), initially set at €2.89 billion and subsequently scaled down and partly replaced by other funds. As at 21 March 2025, total public financing recorded in ReGiS amounted to €19.4 billion; in addition to NRRP resources, further financing from the State and from local authorities was in fact included. The scope of the interventions is broad, encompassing community care – for which standards were defined for the first time through one of the reforms envisaged by the NRRP (Ministerial Decree 77/2022) – hospital care, research and training.
Despite the abundance of data and information, some caution is required when assessing the progress made. Reconstructing the implementation status of the NRRP is not straightforward. Four aspects should be considered: the difficulties of interpreting the data; the need to trace the changes made to the NRRP; the updates to regional programming of interventions, which often disregards and goes beyond the NRRP targets; the inconsistencies between the different information sources, which are not always immediately explicable. As regards the NCIP, the margins of uncertainty are even greater, also because the report by the State General Accounting Department on the related progress has not been updated to 2024.
Taking these elements into account, the analysis shows, first, that the deadlines agreed at European level for the Health Mission have so far been met, but that the next milestones will be the most difficult to complete, especially where it is necessary to bring worksites rapidly to a close (81.7 per cent of projects are at the implementation or completion stage) and to finalise works that have not yet started. This would require performance that is decidedly better than the traditional length of time taken to complete public works in Italy. From a financial standpoint as well, expenditure amounts to €2.8 billion, a figure slightly below that scheduled in the spending plan (€3.1 billion), but far from the total volume of resources to be used.
Second, at the current stage of implementation of the investments, there appears to be a possible discrepancy between the approach adopted at the programming stage and actual execution.
In the programming of the NRRP, the southern regions were supported by the requirement that at least 40 per cent of territorially allocable resources be earmarked for them. However, in the presence of a downward revision of the targets for building interventions, and in the absence of regional objectives consistent with the programming, even if the deadlines were met in full compliance with the European milestones, the envisaged territorial rebalancing might not be achieved. In particular, if one considers some of the main building investments – namely those in community health centres (Case della comunità, CdCs), which benefited from a 45 per cent reserve of resources, and in community hospitals (Ospedali di comunità, OdCs) – the earmark should have ensured rebalancing in favour of the regions with lower infrastructure endowments. It should be noted, however, that these are not all the regions in central and northern Italy and that, therefore, within these macro-areas some regions are set to remain disadvantaged. The picture changes significantly when the focus shifts to the completion of the new facilities. The initial allocation of at least 40 per cent of NRRP resources that can be allocated territorially to the southern regions may not ensure that 40 per cent of expenditure is actually carried out in these regions. The location of worksites that are at the implementation or completion stage is not, in fact, consistent with the distribution of resources and with the related programming, and different levels of progress can be observed across regions. In particular, a more pronounced delay is evident in the southern regions, which would call into question the territorial rebalancing if, once the European targets have been achieved, attention to completing the scheduled works – which are nonetheless intended to be carried out, including with other resources – were to diminish. This would make it even more difficult to meet the standards of the reform of community care, which are more ambitious than those of the NRRP, throughout the national territory.
Third, the examination of the other interventions confirms that a strong effort is still needed to complete the measures, which have indeed been launched, so as to produce a substantial impact on the availability and quality of services and thus on the effective strengthening of the INHS. The use of the electronic health record, the regulatory framework for which has required numerous legislative and regulatory interventions – including in order to address issues related to data-protection rules – is still limited. As regards home care, Territorial Operations Centres (COTs) are operational; the latest information available on the population receiving integrated home care dates back to 2023, when the increase did not appear to be uniform across the country, and, as regards telemedicine, a slowdown has been observed, although the target has become more ambitious, also thanks to the new funding provided under the revised Plan. With reference to the digitalisation of emergency and acceptance departments (DEA), the amounts invoiced are not reassuring, considering that this measure must be completed by the end of the year and that some central and southern regions are very far behind. As for the purchase of equipment, after a start hampered by various difficulties (ranging from price increases to problems in synchronising replacements), rapid progress is now being made, although some regions are still behind, particularly as regards delivery and testing. For the measure concerning intensive and semi-intensive care beds, developments differ across regions. In the area of training, some targets have already been achieved, and in the field of research several calls have been published, rankings have been approved and the funding of some projects has begun.
Fourth, the implementation of investments does not in itself ensure that the new facilities will become fully operational. The success of the Health Mission also depends on the ability to staff the new or upgraded facilities with suitably trained professionals. At present, few services are provided in community health centres and community hospitals, especially in the southern regions, and it is not clear to what extent the new intensive and semi‑intensive care beds are staffed by additional healthcare personnel. This is partly due to the fact that worksites are still open. In a situation of shortages of healthcare staff such as the current one (especially nurses and some medical specialties, but also general practitioners), which persists despite the resumption of hiring in recent years and especially after the spread of the pandemic, a recruitment plan appears to be indispensable. At the time the NRRP was approved, this had emerged as one of the most serious gaps in the overall project to strengthen the INHS, but additional funding for staff has been provided by the Budget Laws for 2022 and 2024. It is therefore necessary to assess whether these resources, whose overall amount is not negligible, are sufficient and to check whether the regions are making use of them, whether they face difficulties due to a lack of managerial capacity or problems with budgetary balance, or whether criticalities instead arise from low participation in recruitment procedures, a phenomenon that is becoming more widespread owing to the declining attractiveness of the INHS.
Finally, it should be noted that on 19 May the NRRP Steering Committee approved a proposal for a technical revision of the Plan, which has been submitted to Parliament for scrutiny. The European Commission and the Council are expected to approve it by the end of June 2025. The Health Mission would be only marginally affected by the revisions, which would essentially consist of definitional changes and bringing forward some targets.
