If there is one area of Italian society that better than any other reflects the growing inequalities in our country, that area today is probably healthcare: 5.8 million citizens, every year, forgo at least one important healthcare service because of money. Because they cannot afford to get treatment. This is one of the most sobering figures in the report "La misura della disuguaglianza. Crisi del Servizio sanitario nazionale e divari nell'accesso alla prevenzione e alle cure oncologiche in Italia", which Medici del mondo presented to the Chamber of Deputies.

Even if this is not an entirely new figure (it comes from the latest Istat report), it is used here to lay bare a situation that is steadily worsening, with marked differences depending on which part of Italy you come from: in short, a genuine indicator of social inequality. The document uses oncology in particular as a mirror through which to read the structural fragilities of the entire public health system. And it is a mirror that reflects something difficult to ignore: the right to healthcare in Italy depends on where you live, how much you earn, and how well you can navigate the bureaucratic labyrinth.

Getting treatment in a system hollowed out over twenty years

The crisis of the National Health Service, Medici del Mondo explains, is not a recent emergency. It is, rather, the outcome of a process spanning more than two decades, shaped by progressive cuts, unfinished reforms and a demand for care increasingly diverted towards the private sector. Between 2010 and 2019, the public health system was deprived of, or simply not allocated, over 37 billion euros compared with planned levels. The result is that public healthcare spending today stands at 6.3 per cent of GDP, below both the OECD and European averages. And according to projections from the Budget Law, the percentage risks falling further still, making getting treatment a genuine privilege for the few.

Meanwhile, the private sector is growing: in 2023, the leading private healthcare groups in Italy exceeded 12 billion euros in revenues, an increase of 15.5 per cent compared with the pre-pandemic period. This figure neatly describes the mechanism at work: the public system weakens, waiting lists grow longer, and those who can afford it go elsewhere. But the money to pay accredited private providers still comes from public funds, siphoning resources away from structural investment.

A vicious circle, as the report calls it, that only amplifies inequalities: citizens' direct healthcare expenditure has reached 41.3 billion euros, equal to 22.3 per cent of total healthcare spending. In practice, those who can afford it pay for treatment out of their own pocket; those who cannot, go without. This share has steadily exceeded 15 per cent for over a decade — the threshold the World Health Organisation identifies as the point beyond which the universality and equity of care are put at risk.

A country at two speeds

What makes matters even worse is that while the problems of the Ssn run across the entire national territory, it is in the divide between north and south that they manifest most acutely. The oncology data examined in the report makes this almost cruelly apparent: in Italy in 2023, approximately 395,000 new diagnoses of malignant tumours were estimated, yet not all patients have the same chances of detecting it in time, of receiving prompt treatment, or of accessing the most innovative drugs.

Uptake of organised mammography screening reaches 63.2 per cent in the north, while it falls to 40.1 per cent in the south and on the islands. For colorectal cancer screening, the gap is even wider: 46.8 per cent in the north against 21.1 per cent in the Mezzogiorno. Calabria is the extreme case, where barely 22.1 per cent of the population participates in organised mammography screening, and for colorectal cancer the figure drops to a meagre 5.2 per cent.

As Dr Michelino De Laurentiis, head of the Senology Department at the Pascale hospital in Naples, explains: "This is not simply a matter of lower awareness or sensitivity among the population, but above all of organisational problems, such as staff shortages, inconsistent invitation letters and excessively long waiting times." The consequences can also be measured in avoidable deaths: cancer mortality in the south stands at 8.4 deaths per 10,000 inhabitants, compared with fewer than 7.3 in the rest of the country. A difference that translates into thousands of lives every year.

Real lives, not just numbers

But since patients are not cold statistics but flesh-and-blood people with voices, here are some first-hand accounts gathered by the report. Such as that of Elisa, a pseudonym, a psychologist and psychotherapist who went through a cancer diagnosis and treatment in 2022 in Veneto and who describes what it means to seek care in one of the regional health systems considered among the most efficient in Italy: before starting chemotherapy, Elisa had to address the issue of fertility preservation through medically assisted reproduction. "Only one of the three drugs in the protocol is in class A," she explains, "meaning it is covered by the health system. I had to pay 640 euros out of my own pocket. This was a very significant form of financial toxicity." And then there is the wig: quality hairpieces can cost up to 1,800 euros, but the Veneto Region offers a maximum contribution of 400 euros, prioritised for people with income-based exemptions. Being self-employed with a VAT number made it practically impossible for Elisa to actually access that reimbursement.

But the most bitter account concerns follow-up care — the system of check-ups that is supposed to accompany cancer patients for years after the end of treatment. "Since September 2024, the Veneto Region has centralised the booking system for patients in follow-up," Elisa recounts. "I am in my third year. Since September 2024 I am still waiting to be called for the CT scan and breast ultrasound I need to have done by 13 October, because I have an appointment for which I will need to arrive with the results already reported." If nobody calls her, she will have to pay more than 600 euros out of her own pocket, despite the exemption for oncological conditions. "This is not just about me, but about a system that does not respect what science tells us is the appropriate timeframe for care."

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Those who work inside the public system witness its contradictions from within. Dario, a doctor in Veneto's onco-haematology department, describes a mechanism he calls "the corporatisation of the Ssn". The funding exists, he says, but "it is managed inefficiently, without any comprehensible logic of priorities." Radiologists are fleeing to the private sector, where they earn three times as much. Public hospitals then find themselves having to hire locum doctors, while simultaneously funding private providers through accreditation agreements. Dario also speaks of those who disappear from the system before even receiving a diagnosis: patients with mental illness, migrants, people in detention. "It doesn't mean they don't get sick, but that we lose them. We fail to connect them to services in time to make diagnoses." These are the people who, when they do eventually arrive, arrive already too late.

Proximity saves lives

In Arghillà, a peripheral neighbourhood of Reggio Calabria, the Medici del Mondo team has been working for years to tear down the barriers that keep the most vulnerable people away from prevention. Not only economic barriers, but cultural and emotional ones too: the fear of receiving a diagnosis, distrust of the healthcare system, the feeling of not belonging to it. In July 2025, thanks to this "gradual and non-judgemental" work, a 61-year-old woman who had always refused any screening took part for the first time in an early breast cancer detection session. The examination identified a suspicious clinical picture. The ultrasound revealed highly suspicious bilateral masses. Thanks to the immediate intervention of the team and collaboration with the local health service, in less than two months all diagnostic tests had been completed, surgery had been performed and a course of radiotherapy had been completed, both with positive outcomes. Today that woman has become a promoter of screening in her neighbourhood. It is a single case, yet it says something essential: when the right barriers are broken down, using the right methods, even those furthest from the system can be reached and cared for.

"The risk is that a two-speed system becomes further entrenched," warns Mario Braga, vice-president of Medici del Mondo Italia: "Instead of investing structurally in strengthening the Ssn, we continue to compensate for its weaknesses by channelling resources towards the accredited private sector." Director Elisa Visconti is even more direct: "If resources can be found to increase other strategic areas of expenditure, starting with defence, then the resources needed to guarantee a truly universal, accessible and effective national health service must be found as well."

To move closer to European standards, economist Serenella Caravella of Svimez points the way: raising healthcare spending from 6.6 per cent to around 9 per cent of GDP. A necessary condition to "stem the qualitative decline across the country and set out on a path of reducing territorial inequalities." In the meantime, the 5.8 million Italians who in 2024 gave up on seeking care are waiting. Not for an abstract answer, but for a visit, a test and an appointment that arrives in time.