40 years ago, Italy saw the birth of a national, universal health-care system (Servizio Sanitario Nazionale [SSN]), which provides a full range of health-care services with a free choice of providers. The SSN is consistently rated within the Organisation for Economic Co-operation and Development among the highest countries for life expectancy and among the lowest in health-care spending as a proportion of gross domestic product. Italy appears to be in an envious position. However, a rapidly ageing population, increasing prevalence of chronic diseases, rising demand, and the COVID-19 pandemic have exposed weaknesses in the system. These weaknesses are linked to the often tumultuous history of the nation and the health-care system, in which innovation and initiative often lead to spiralling costs and difficulties, followed by austere cost-containment measures. We describe how the tenuous balance of centralised versus regional control has shifted over time to create not one, but 20 different health systems, exacerbating differences in access to care across regions. We explore how Italy can rise to the challenges ahead, providing recommendations for systemic change, with emphasis on data-driven planning, prevention, and research; integrated care and technology; and investments in personnel. The evolution of the SSN is characterised by an ongoing struggle to balance centralisation and decentralisation in a health-care system, a dilemma faced by many nations. If in times of emergency, planning, coordination, and control by the central government can guarantee uniformity of provider behaviour and access to care, during non-emergency times, we believe that a balance can be found provided that autonomy is paired with accountability in achieving certain objectives, and that the central government develops the skills and, therefore, the legitimacy, to formulate health policies of a national nature. These processes would provide local governments with the strategic means to develop local plans and programmes, and the knowledge and tools to coordinate local initiatives for eventual transfer to the larger system.

40 年前，意大利诞生了一个全国性的全民医疗保健系统（Servizio Sanitario Nazionale[SSN])，它提供全方位的医疗保健服务，可以自由选择提供者。SSN 在经济合作与发展组织内一直被评为预期寿命最高的国家和医疗保健支出占国内生产总值比例最低的国家之一。意大利似乎处于令人羡慕的境地。然而，人口迅速老龄化、慢性病患病率增加、需求增加以及 COVID-19 大流行暴露了该系统的弱点。这些弱点与国家和医疗保健系统经常动荡的历史有关，在这些历史中，创新和主动性往往导致成本和困难的螺旋式上升，随之而来的是严格的成本控制措施。我们描述了集中控制与区域控制之间的微弱平衡如何随着时间的推移而转变，以创建不是一个而是 20 个不同的卫生系统，从而加剧了跨区域获得医疗服务的差异。我们探索意大利如何应对未来的挑战，为系统性变革提供建议，重点是数据驱动的规划、预防和研究；综合护理和技术；和人事投资。SSN 演变的特点是在医疗保健系统中平衡集权和分权的持续斗争，这是许多国家面临的困境。如果在紧急情况下，中央政府的计划、协调和控制可以保证在非紧急情况下提供者行为和获得护理的一致性，我们认为，如果自治与实现某些目标的责任相结合，中央政府发展技能，从而发展制定国家性质的卫生政策的合法性，就可以找到平衡。这些过程将为地方政府提供制定地方计划和方案的战略手段，以及协调地方举措以最终转移到更大系统的知识和工具。