The Right to Healthcare in Inner and Mountain Areas From Territorial Difference to Equal Access: The Case of Liguria

The right to health is recognised by Article 32 of the Italian Constitution as a fundamental right of the individual and an interest of the community. However, recognising this right does not necessarily mean that everyone can exercise it under the same conditions. In Italy, healthcare is organised through a regional system, and access to services depends on where people live, the availability of healthcare professionals, the organisation of local services, and the territory’s geographical characteristics. These differences are more evident in inner and mountain areas, where distance, population ageing, demographic decline, and the progressive reduction of essential services can make accessing healthcare more difficult. This thesis begins with a central question: how can the constitutional right to health be effectively guaranteed to everyone when the territorial conditions in which healthcare is provided differ so much? The research examines this question through the relationship between the right to health, substantive equality and territorial autonomy in the Italian constitutional system. Attention is given to Articles 3(2) and 32 of the Constitution, the distribution of healthcare responsibilities between the State and the Regions, and the role of the Essential Levels of Care (LEA) in preserving common guarantees throughout the national territory. The thesis argues that differences in healthcare organisation do not necessarily result in unequal protection. In some circumstances, adapting services to a territory’s geographical, demographic, and social characteristics may be necessary to ensure individuals can effectively access care. The constitutional problem arises when territorial differences, together with organisational weaknesses, place residents of certain areas in a systematically weaker position when seeking healthcare. The study adopts a predominantly legal-doctrinal and interpretative methodology, drawing on constitutional principles, legislation, Constitutional Court jurisprudence and national and regional planning documents. This analysis is complemented by selected demographic, territorial, and healthcare indicators that help explain the material conditions under which constitutional guarantees are implemented. The research examines the legal and institutional framework governing inner and mountain areas, the National Strategy for Inner Areas (SNAI), and the reorganisation of territorial healthcare introduced through the National Recovery and Resilience Plan (PNRR) and Ministerial Decree n. 77/2022. It also considers the role of digital healthcare and telemedicine, especially their potential to reduce geographical barriers and the limitations that may prevent these services from improving accessibility in practice. Liguria is examined as a case study because it brings together metropolitan and coastal areas, small inner municipalities and mountain territories within the same regional healthcare system. Its geography, demographic ageing, and uneven distribution of services and healthcare professionals provide a useful context for examining how territorial differences affect access to care. The analysis considers the organisation of the regional healthcare system and its recent reforms, with attention to territorial services, workforce availability, home healthcare, waiting times, healthcare mobility and digital connectivity. The Ligurian case shows why the presence of healthcare facilities or the adoption of new organisational models cannot, by themselves, establish whether care is effectively accessible to the people who need it. Building on this analysis, the thesis develops equal access as an analytical criterion for examining the constitutional relevance of territorial differences in healthcare. The proposed criterion brings together four dimensions: the justification of territorial differentiation, the preservation of common healthcare guarantees, substantive equality in effective access and the practical implementation of healthcare services. These dimensions draw on the constitutional and organisational questions examined throughout the research and assess whether differentiated arrangements allow individuals to access and complete the healthcare pathway appropriate to their needs under reasonably comparable conditions. The criterion is not a separate legal test established by constitutional jurisprudence, but an interpretative framework for considering how the principles of equality and health protection apply across different territorial circumstances. The research concludes that ensuring equality in healthcare does not require identical structures or organisational arrangements in every territory. Rather, it requires public institutions to consider the actual conditions under which people can access the care guaranteed to them. In inner and mountain areas, this may involve combining local services with specialist networks, home healthcare, appropriate digital solutions and stronger coordination between healthcare institutions and local authorities. The effective protection of the right to health therefore depends on how those guarantees are implemented in territories with different needs and resources, as well as on the existence of common legal guarantees. Territorial differences do not necessarily conflict with equality, but they cannot justify systematically weaker access to healthcare.