The World Health Organization speaks clearly: fraud, abuse and corruption are not simple bureaucratic anomalies, but phenomena that impact the sustainability of healthcare systems. In Italy, the intersection between a massive financial volume and structural complexity makes the National Health Service a terrain exposed to illegality, inefficiencies and ethical gray areas. Annual public health spending exceeds 140 billion euros: an enormous financial mass, which requires effective controls and transparency.

“Precisely because the world of health is so essential and linked to people’s lives, when corruption occurs in this sector it does more harm: it undermines fundamental rights, undermines the principle of equality and above all causes resources that are always scarce compared to needs to be wasted,” said Giuseppe Busia, president of the National Anti-Corruption Authority, during the event “Fraud and abuse in healthcare”, organized by the Gimbe Foundation.

The recent worsening of corruption perception indices in our country raises an alarm bell that cannot be ignored by politicians and institutions. It is in this scenario that the memorandum of understanding and the strategic discussion between Anac and the Gimbe Foundation are inserted. The objective is to trace a scientific taxonomy of fraud and abuse, map the risk and structure more effective defenses to protect the most precious public good: health.

Vulnerability factors

As highlighted by the analysis of the Gimbe Foundation, the reasons why healthcare is structurally exposed to corruption phenomena and conflicts of interest lie in some organizational and contextual characteristics.

The first is the fragmentation of the system: management responsibility distributed on a regional and local basis makes uniform controls more complex. The second is information asymmetry, that is, the disparity in knowledge between those who provide services, those who produce technologies and those who must govern or receive care. Added to this is the high decision-making discretion that characterizes clinical, purchasing and regulatory choices.

Then there is the social normalization of small daily abuses, often accompanied by the silence of those who should report, and the political and commercial pressures, which can distort the governance of the system in favor of private interests.

From punitive logic to prevention

The approach to the phenomenon has changed over time. Before the 1980s, corruption was often reduced to a problem of non-compliance with the rules, to be addressed above all with criminal sanctions. In the 2000s, however, a paradigm shift took hold: today corruption is recognized as a systemic pathology linked to the context.

The pandemic then exposed the fragilities of global governance, demonstrating that the only sustainable strategy cannot be ex post intervention alone. We need a culture of prevention, based on transparency, traceability and timely controls.

The risk categories

The work of the Gimbe Foundation has identified 65 types of fraud and abuse: from criminal crimes to administrative offences, up to ethically reprehensible but not always formally illegal conduct. The point is not to chase every single deviation, but to understand its overall impact. Even phenomena with low economic impact, if very frequent, can erode the system as much as large isolated scandals.

The risk of corruption and mismanagement can creep into every level of the healthcare system. It starts at the highest levels of governance and regulation, where aggressive lobbies can influence public health policies or drug approval and reimbursement processes. It continues in clinical research and marketing, where poorly managed funds, falsified data and conflicts of interest can distort scientific production and professional training.

On an operational level, the gray areas concern economic and logistical management: rigged tenders, anomalies in warehouses, unclear budgets. Finally, ethical degradation can extend to direct relationships with citizens and healthcare personnel: hiring based on recommendations, manipulation of waiting lists, incorrect use of private activity in the hospital and falsification of clinical documents to obtain higher reimbursements.

The impact on citizens

The consequences of these behaviors are not only measured in euros subtracted from public coffers. The estimates circulated speak of 7 billion per year, but the experts themselves invite us to consider these figures as an order of magnitude, not as a precise measurement. The deepest damage falls on the quality of care, equity of access and citizens’ trust.

The impact is divided into four directions. The first concerns public health: fraud and abuse can reduce the quality of care, favor inadequate products or services and increase delays and inequalities. The second concerns public finance: the erosion of resources takes away from the system funds necessary for innovation, personnel and essential levels of assistance.

The third guideline is equity of access. Manipulated waiting lists and improper shortcuts push citizens towards the private sector or towards giving up treatment, widening social inequalities. The fourth is trust in institutions: when the care pact is betrayed, the relationship between citizens, health professionals and the State breaks down.

The tools for change

The institutional response cannot only be repressive. It must be based on advanced managerial tools, integrated controls and greater prevention capacity. The centralization of purchasing and the strengthening of digital platforms can increase the transparency of tenders and guarantee a more open and controllable market.

At the same time, the protection of whistleblowing – the reporting of crimes, frauds or irregularities by employees, collaborators or suppliers – remains an essential tool to break the silence within healthcare facilities and protect those who choose the path of integrity.

The challenge launched by Anac and Gimbe reminds us that defending the National Health Service from fraud means defending democracy, equity and the constitutional right to health. It is no longer a time for postponements: transparency must become the first structural therapy for our NHS.