This open access Palgrave Pivot provides a rigorous interdisciplinary analysis of one of Europe’s most complex decentralised healthcare systems. Using Italy as a detailed case study, the book examines how fiscal sustainability, regional governance, and demographic ageing interact to shape health system performance across OECD countries. Integrating public finance, health economics, spatial epidemiology, and applied econometrics, it analyses long‑run trends in healthcare spending, the macroeconomic role of health investment, and the institutional tensions between regional autonomy and the constitutional requirement to guarantee uniform service levels.

Advancing both academic and policy debates, the volume introduces innovative methodological tools including financial perequation models, multi‑directional composite indicators, and Complex Network Theory, to diagnose territorial disparities, evaluate hospital performance, and map patient mobility dynamics. These analytical approaches provide policymakers with operational frameworks for improving allocative efficiency and addressing persistent North–South divides, while supporting scholars working on decentralisation, health equity, and public sector evaluation. The book positions the Italian NHS as an empirical case study for testing equitable and efficient governance under fiscal constraint, offering insights relevant to international discussions on sustainable and resilient health systems. It will be of interest to scholars and policymakers working in health economics, public health policy, public sector studies and public finance.

Francesco Vidoli is Associate Professor of Economic Statistics at the University of Urbino Carlo Bo and Principal Investigator of the TEMME‑Health project. His research focuses on public service efficiency, spatial econometrics, and modelling essential expenditure needs. He has published widely in health economics and public sector evaluation and brings extensive expertise in quantitative policy analysis.