JUDGMENT NO. 9

YEAR 2026

ITALIAN REPUBLIC

IN THE NAME OF THE ITALIAN PEOPLE

THE CONSTITUTIONAL COURT

composed of:

President: Giovanni AMOROSO;

Judges: Francesco VIGANÒ, Luca ANTONINI, Stefano PETITTI, Angelo BUSCEMA, Emanuela NAVARRETTA, Maria Rosaria SAN GIORGIO, Filippo PATRONI GRIFFI, Marco D’ALBERTI, Giovanni PITRUZZELLA, Antonella SCIARRONE ALIBRANDI, Massimo LUCIANI, Roberto Nicola CASSINELLI,
has pronounced the following

JUDGMENT

in the constitutional legitimacy reviews of Article 26 of the Law of the Puglia Region of November 29, 2024, No. 39 (Financial and Miscellaneous Provisions. Amendment to the Budget Forecast for the fiscal year 2024 and the multi-year period 2024-2026) and of Article 240 of the Law of the Puglia Region of December 31, 2024, No. 42, concerning "Provisions for the preparation of the 2025 budget forecast and the multi-year budget 2025-2027 of the Puglia Region (Regional Stability Law 2025),” initiated by the President of the Council of Ministers, with appeals served, respectively, on January 29, 2025, and February 28, 2025, filed in the Registry on January 29, 2025, and March 1, 2025, registered under appeal numbers 7 and 12 of the 2025 appeal registry and published in the Official Gazette of the Republic numbers 9 and 12, first special series, of the year 2025.

Having reviewed the statements of defense of the Puglia Region;

Having heard Judge Rapporteur Antonella Sciarrone Alibrandi in the public hearing of November 5, 2025;

Having heard the State Attorney Davide Di Giorgio for the President of the Council of Ministers, as well as Attorney Paolo Scagliola for the Puglia Region;

Deliberated in the council chamber of November 5, 2025.

Matters of Fact Considered

1.– By appeal served on January 29, 2025, and filed on the same date, registered under No. 7 of the 2025 appeal registry, the President of the Council of Ministers, represented and defended by the Advocate General of the State, challenged, among others, Article 26 of the Law of the Puglia Region of November 29, 2024, No. 39 (Financial and Miscellaneous Provisions. Amendment to the Budget Forecast for the fiscal year 2024 and the multi-year period 2024-2026).

This provision, entitled "Establishment of the RSA in San Nicandro Garganico and Troia,” is intended to effect the transfer of these welfare facilities – until then managed by a private company (Sviluppo e gestione di attività sanitarie srl) – to wholly public management, through their integration into the functional organization of the Local Health Authority (ASL) of Foggia. It is specifically provided that "the transfer to wholly public management of the RSA [shall occur] upon the expiration of the current or extended management contracts” (paragraph 3) and that the transfer of personnel in service on the date of entry into force of the law into the staff of the competent ASL shall be carried out "pursuant to Article 1, paragraph 268, letter c) of Law of December 30, 2021, No. 234 (State Budget Forecast for the fiscal year 2022 and multi-year budget for the three-year period 2022-2024), in compliance with the current legislation, where compatible with the professional profile, enhancing the work experience gained in the same type of service” (paragraph 4).

In the opinion of the appellant, the regional provision would conflict with Articles 97 and 117, third paragraph, of the Constitution, on several grounds.

Firstly, Article 97, fourth paragraph, of the Constitution would be violated, as the foreseen transfer of personnel from a private to a public employer would constitute a "not permitted derogation from ordinary competitive procedures,” violating Presidential Decree No. 483 of December 10, 1997 (Regulation establishing competitive procedures for managerial personnel of the National Health Service) and Presidential Decree No. 220 of March 27, 2001 (Regulation establishing competitive procedures for non-managerial personnel of the National Health Service), issued in implementation of Articles 15 and 18, paragraph 1, of Legislative Decree No. 502 of December 30, 1992 (Reorganization of the discipline in the healthcare sector, pursuant to Article 1 of Law No. 421 of October 23, 1992), which provide for recruitment procedures for healthcare personnel through competitions based on qualifications and examinations, differentiated according to the various professional profiles.

In this regard, the appellant considers the cited application of Article 1, paragraph 268, letter c), of Law No. 234 of December 30, 2021 (State Budget Forecast for the fiscal year 2022 and multi-year budget for the three-year period 2022-2024), referred to by the challenged Article 26, to be irrelevant, since the state provision "concerns only the selection procedures for recruitment of personnel by entities of the SSN, not direct internalization without public competition.” The reference to the state provision would also be improper, as the regional rule appears to refer generally to "personnel in service” without distinguishing between the various professional profiles.

Article 117, third paragraph, of the Constitution would also be violated, due to conflict with the fundamental principles established by the State in the matter of "health protection,” as no particular emergency or extraordinary situations exist that would justify derogations from the principle of competition.

Furthermore, Article 26 of Puglia Regional Law No. 39 of 2024 is contested with reference to Articles 97, first paragraph, and 117, third paragraph, of the Constitution, concerning the determination of fundamental principles regarding the "coordination of public finance,” as it is considered contrary to the objectives set in the recovery plan from the healthcare deficit, to which the Puglia Region is bound by virtue of the Agreement signed with the Ministers of Health and Economy and Finance on November 29, 2010.

For the appellant, the transfer of personnel into the ASL staff, with the connected financial burdens, "prejudices the achievement of the objective of containing expenditure for healthcare personnel,” in violation of Article 2, paragraphs 80 and 95, of Law No. 191 of December 23, 2009, concerning "Provisions for the preparation of the annual and multi-year State budget (Financial Law 2010),” which establishes the binding nature of the interventions identified in the recovery plan, requiring regions subject thereto to remove legislative or other provisions that obstruct the full implementation of the programmed interventions, and not to adopt new ones.

Moreover, the regional legislative intervention would not have been communicated in advance to the competent Ministers in order to verify its compatibility with the implementation of the recovery plan, nor would it have been coordinated with the operational program for the continuation of the 2024-2026 plan – specifically aimed at identifying the necessary interventions for achieving economic balance while respecting the essential levels of assistance (LEA), pursuant to Article 1, paragraph 180, of Law No. 311 of December 30, 2004, concerning "Provisions for the preparation of the annual and multi-year State budget (Financial Law 2005)” – despite "the evident and significant impact on the Region's financial resources” and the determination of "a tangible increase in healthcare expenditure,” thus realizing an undue modification of healthcare programming, in violation of the prohibition on increasing expenditure for reasons not pertaining to the guarantee of LEA.

2.– By appeal served on February 28, 2025, and filed on the following March 1, registered under No. 12 of the 2025 appeal registry, the President of the Council of Ministers then challenged, among others, Article 240 of the Law of the Puglia Region of December 31, 2024, No. 42, concerning "Provisions for the preparation of the 2025 budget forecast and the multi-year budget 2025-2027 of the Puglia Region (Regional Stability Law 2025),” which amended Article 26 of Puglia Regional Law No. 39 of 2024, by adding the RSA of Campi Salentina – to be included in the functional organization of the ASL of Lecce – and a new definition of the terms of succession and the number of beds.

Also concerning this provision, the appellant alleges the violation of the same constitutional parameters invoked in the appeal registered under No. 7 of the 2025 appeal registry, based on arguments identical to those already presented.

Furthermore, regarding the contested direct transfer of personnel into the staff of the territorially competent ASL, a question of constitutional legitimacy is also raised with reference to Article 117, second paragraph, letter l), of the Constitution, "which reserves to the exclusive competence of the State the civil legal system and therefore private law relationships governed by the Civil Code, such as those involving collective labor agreements.”

3.– The Puglia Region has defended itself in both proceedings, arguing for the inadmissibility and lack of merit of the questions raised by the President of the Council of Ministers.

As to the first point, the respondent pleaded the inadmissibility of the questions regarding the "alleged violation of constitutional norms concerning the coordination of public finance and budget balance,” as no demonstration was provided of the claimed breach of the constraints imposed by the recovery plan, nor of the real extent of the costs.

It further argued, concerning the alleged violation of Article 117, second paragraph, letter l), of the Constitution, the inadmissibility of the question due to an absolute lack of reasoning and mere assertion in the challenge.

As to the merits, the Puglia Region points out that the RSAs in question, despite the title of the provision, are not "newly established” structures, but rather healthcare facilities already existing and operational for some time in the regional territory, having been publicly owned by the relevant ASL from their inception and falling within the scope of the reorganization process of the socio-health sector initiated by Puglia Regional Law of December 12, 2017, No. 53 (Reorganization of Puglian socio-health structures for residential assistance to non-self-sufficient persons. Establishment of RSAs of high, medium, and low care intensity), with particular reference to residential facilities for non-self-sufficient subjects (elderly and persons with dementia), such as the RSAs under examination. This is allegedly demonstrated by regional planning and recognition acts, such as Regional Council Resolution of March 19, 2002, No. 210, approving Regional Regulation of December 20, 2002, No. 8 (Regulation on the organization and functioning of RSAs), and Table A) (R.R. No. 4/2019 - art. 9, paragraph 3, letter a - beds/semi-residential places in former public RSAs already authorized for operation or already provided for in regional health planning acts), contained in Annex A to Regional Council Resolution of November 25, 2019, No. 2153 (R.R. No. 4/2019 - art. 12.1 - Recognition act of structures included among those authorized for operation pursuant to art. 9, paragraph 3, and of beds/places included in the accreditation requirement pursuant to art. 10, paragraphs 3 and 4 - Beds/places available for the issuance of new authorizations for operation and accreditation) – both attached to the statement of defense.

Therefore, contrary to the appellant’s erroneous belief, these are not accredited private facilities, but rather facilities of public ownership from the outset, entrusted to a private entity that managed them on behalf of the ASLs and to whom the employment relationships with the operating personnel were attached.

In this regard, the Puglia Region refers to the analogous case of the management transfer of the Ceglie Messapica Rehabilitation Center, regulated by Puglia Regional Law of May 30, 2024, No. 21, concerning "Establishment of the Public Hospital Rehabilitation Regional Center of Ceglie Messapica (CRRiPOCeM),” which was the subject of a previous challenge by the President of the Council of Ministers before this Court, appeal registered under No. 25 of the 2024 appeal registry.

The challenged regional legislation would therefore not entail any increase in expenditure to the detriment of the constraints connected to the recovery plan, as "the costs for the services rendered by the facilities were (as they currently are) already charged to the budgets of the respective ASLs, regardless of the legislative supervening event.”

The respondent in fact highlights that the RSAs in question are currently active with beds fully occupied by patients for whom the competent ASLs recognize the healthcare share, as reported in the technical documentation attached to the statement of defense. Consequently, there would be no increased burden on the Regional Health Service (SSR) since "[a]ssisted persons directly remunerate the current manager for 50% of the current daily rates, in compliance with the DPCM for LEA”; a share that, following the challenged regional law, would now be collected by the ASL and, together with the remaining 50 percent already remunerated by the SSR, "would in any case cover the total costs for the direct management of the facility.”

This implies "intrinsic coherence with the 2024-2026 Operational Program for the continuation of the recovery plan to which the Puglia Region is committed, as well as with the regional planning of beds in the reference setting,” precluding the need for prior ministerial consultation, as the matter concerns the provision of LEA and thus mandatory healthcare expenditures.

Regarding the alleged violation of competitive procedures, the Puglia Region contests its foundation, observing that the reference made to Law No. 234 of 2021 and "current legislation” rather implies the regional legislator’s intention to subject the procedure for the transfer of personnel into the health authority’s staff to compliance with all current legislative constraints – such as those provided for in matters of personnel expenditure and hiring capacity – leaving no room for hiring methods alternative to those expressly provided for by state law.

Therefore, no direct transfer of personnel occurs. Rather, in the regional defense’s view, the decision on how to employ a portion of the resources in healthcare matters, taking into account expenditure constraints and public finance needs, in compliance with the personnel expenditure ceiling under former Article 11 of Decree-Law No. 35 of April 30, 2019 (Emergency Measures for the healthcare service of the Calabria Region and other urgent measures in the healthcare sector), converted, with modifications, into Law No. 60 of June 25, 2019, pertains to regional organizational autonomy falling under its residual legislative competence, pursuant to Article 117, fourth paragraph, of the Constitution, or concurrent competence in the matter of health protection.

It further points out that, by Regional Council Resolution of December 12, 2022, No. 1818 (attached to the statement), the expenditure ceiling was determined, allocated per ASL/Entity of the SSR, showing over 70 million euros of unused expenditure, deriving both from additional ministerial resources stemming from the Decree of the Minister of Health, jointly with the Minister of Economy and Finance, No. 77 of May 23, 2022 (Regulation defining models and standards for the development of territorial assistance in the National Health Service), and from the non-full utilization of the expenditure ceiling determined on the 2022 National Health Fund by the ASLs of Foggia and Lecce, as well as from economic resources resulting from cessations in the ASL of Brindisi 2025. Consequently, by Council Resolution of December 23, 2024, No. 1876 (attached), the new expenditure ceiling for SSR entities was defined, thus excluding any risk of overrun, as alleged by the appellant.

4.– Close to the public hearing, the Puglia Region filed a defense brief in both proceedings, insisting on the inadmissibility and lack of merit of the questions raised.

The respondent specifically highlighted, based on cost analyses conducted by the ASLs of Foggia and Lecce (as per notes prot. No. 0520431 of September 25, 2025, and prot. No. 178566 of October 3, 2025, attached to the brief), that the internalisation concerning the RSAs "represents a virtuous application” of the principles of public finance coordination, "resulting in a proven and significant rationalization of resources.” Indeed, it generates a net annual expenditure saving of 411,269.60 euros for the RSA of Troia, 75,553.95 euros for that of San Nicandro Garganico, and 352,950.63 euros for the RSA of Campi Salentina.

It is further specified that the challenged intervention is not in contradiction with the objectives of the recovery plan, but rather constitutes "an implementing instrument thereof, pursuing the rationalization of expenditure which is a precondition for achieving economic balance while respecting the Essential Levels of Assistance.”

To confirm the legitimacy of the legislative intervention, the Puglia Region finally refers to the recent Judgment No. 57 of 2025 of this Court – of which extensive excerpts are reported – delivered after the filing of the present appeals, which, ruling on the constitutional legitimacy of the Puglian regional legislation concerning the Ceglie Messapica hospital center, recognized its compliance both with the objectives agreed upon in the recovery plan and with healthcare programming, finding only the provision allowing for selection procedures based solely on qualifications, as an alternative to the procedures under Law No. 234 of 2021, to be constitutionally illegitimate; an alternative which is not reproduced in the provision subject to the present review. This further confirms the lack of merit of the complaint regarding the circumvention of competitive procedures.

5.– In the public hearing, the parties insisted on the acceptance of their respective conclusions.
Considered in Law

6.– With two distinct appeals (registered under Nos. 7 and 12 of the 2025 appeal registry), the President of the Council of Ministers, represented and defended by the Advocate General of the State, challenged various provisions of Puglia Regional Law No. 39 of 2024 and Puglia Regional Law No. 42 of 2024.

6.1.– Decisions on the other questions of constitutional legitimacy raised by the same appeals are reserved for separate rulings; here, the examination is focused on those concerning Article 26 of Puglia Regional Law No. 39 of 2024 (challenged by the appeal registered under No. 7 of the 2025 appeal registry) and Article 240 of Puglia Regional Law No. 42 of 2024 (challenged by the appeal registered under No. 12 of the 2025 appeal registry), amending the aforementioned Article 26.

7.– Article 26 of Puglia Regional Law No. 39 of 2024 aims to effect the transfer of the RSAs in San Nicandro Garganico and Troia – until then managed by a private company (Sviluppo e gestione di attività sanitarie srl) – to wholly public management, through their integration into the functional organization of the ASL of Foggia "upon the expiration of the current or extended management contracts.” The same article also provides that the transfer of the relevant personnel into the ASL staff shall occur pursuant to Article 1, paragraph 268, letter c), of Law No. 234 of 2021, in compliance with current legislation, where compatible with the professional profile, enhancing the work experience gained in the same type of service.

With Article 240 of Puglia Regional Law No. 42 of 2024, the regional legislator then amended Article 26 mentioned above, adding reference to the RSA of Campi Salentina, to be included in the functional organization of the ASL of Lecce, and a new determination of the succession terms and the number of beds originally provided for in the challenged provision, which remained unchanged in its remaining part.

8.– Against the regional legislation, the President of the Council of Ministers proposed two distinct challenges, advancing two sets of complaints with nearly identical arguments regarding both challenged provisions and the constitutional parameters invoked.

With the first set, concerning the recruitment procedures for personnel serving in the RSAs, the appellant complains of the violation of Articles 97, fourth paragraph, 117, second paragraph, letter l), and third, of the Constitution, the latter with reference to the matter of "health protection,” believing that the foreseen transfer of personnel into the ASL staff occurs outside the ordinary competitive procedures.

With the second set, relating to compliance with the constraints arising from the recovery plan from the healthcare deficit, under the Agreement signed by the Puglia Region with the Ministers of Health and Economy and Finance on November 29, 2010, the President of the Council of Ministers alleges the violation of Articles 97, first paragraph, and 117, third paragraph, of the Constitution, the latter due to conflict with the fundamental principles established by the State in the matter of "coordination of public finance,” assuming that the regional intervention, not communicated in advance to the aforementioned Ministers, is not in line with the objectives set in the plan and determines an undue modification of healthcare programming.

8.1.– The two appeals raise analogous questions regarding both the challenged provisions and the invoked constitutional parameters, which largely coincide. Therefore, the related proceedings can be joined for a single ruling.

9.– It is appropriate to recall that a legally comparable situation to the one under scrutiny has already been examined in the recent Judgment No. 57 of 2025, filed after the present appeals were lodged, and whose salient points should be recapitulated here.

On that occasion, the subject of the constitutional legitimacy review was the transfer to wholly public management of the Ceglie Messapica Rehabilitation Center, previously entrusted to private entities, as provided for by Puglia Regional Law No. 21 of 2024.

The regional intervention was then challenged by the President of the Council of Ministers for alleged violation of Articles 97, first paragraph, and 117, third paragraph, of the Constitution, the latter for violation of the fundamental principles established by the State in the matters of "coordination of public finance” and "health protection,” as it was considered capable of compromising the full realization of the objectives set by the recovery plan for overcoming the healthcare deficit.

The President of the Council of Ministers also challenged the foreseen inclusion of personnel in the staff of the ASL of Brindisi, considering it a direct transfer in breach of the public competition rule, set forth in the fourth paragraph of Article 97 of the Constitution.

With the aforementioned ruling, this Court found the questions of constitutional legitimacy raised with reference to Articles 97, first paragraph, and 117, third paragraph, of the Constitution, to be unfounded.

In particular – highlighting the peculiar contours of the case (being an "interim assignment of difficult classification”) – it was ruled out that the transfer to public management of the rehabilitation facility introduced "a ‘significant modification of the pre-existing ‘healthcare programming’ [and] a ‘significant increase’ in the financial commitment in the sector,’ both outlined by the appellant as extraneous to the recovery plan objectives and, as such, prohibited to the respondent Region.”

This was based both on the documentation produced by the Puglia Region (consisting of planning acts adopted over the years by the Regional Council, regularly transmitted to and approved by the accompanying Ministries) attesting to the public hospital nature of the facility in question, and on the consideration that the modification of the management structure appeared, in light of the objective of reorganizing the hospital network set in the recovery plan, "even necessary.”

With regard to the financial repercussions, it was clarified that, in this case, services all certainly falling within the essential levels of assistance were at issue, hence mandatory, "so that the challenged regional provisions do not imply further and expanding services compared to those provided by the State.” To this argument – "already self-sufficient” – was added the finding of the absence of an increase in healthcare expenditure linked to the internalization measure, as attested by the technical report of the challenged regional law and the documentation also produced on that occasion by the Puglia Region, which thus proved to have legitimately acted "within the economic-financial framework specifically outlined by the recovery plan.”

Concerning the complaint relating to the direct transfer of personnel, Judgment No. 57 of 2025 deemed the portion of the regional provision (as is also the case here) that refers, for personnel recruitment, to Article 1, paragraph 268, letter c), of Law No. 234 of 2021, immune from the unconstitutionality defect, "which does not permit stabilization without competition: as clarified by Judgment No. 99 of 2023 of this Court, the relevant procedures must be initiated ‘in compliance with the principles established in matters of public competition.’”

The residual regulatory segment (limited to the words "or with selection procedures based solely on qualifications, where compatible with the professional profile”) – not reproduced in the regional provision subject to the present review – which, as an alternative to the procedures under Law No. 234 of 2021, introduced the possibility of hiring, without competition, personnel already employed by the Foundation that had managed the rehabilitation center until that time, was instead declared constitutionally illegitimate.

10.– That being established, turning to the present questions, the President of the Council of Ministers first challenged the foreseen transfer of personnel, operating in the indicated healthcare facilities, into the staff of the territorially competent ASLs, which, under paragraph 4 of Article 26 of Puglia Regional Law No. 39 of 2024 (in both its original and amended versions), must occur "pursuant to Article 1, paragraph 268, letter c) of Law of December 30, 2021, No. 234 […], in compliance with current legislation, where compatible with the professional profile, enhancing the work experience gained in the same type of service.”

According to the appellant’s position, this transfer is carried out in violation of the principle of public competition, under the fourth paragraph of Article 97 of the Constitution, and of the state legislation regulating the hiring of personnel, managerial and non-managerial, of the SSN (Presidential Decrees No. 483 of 1997 and No. 220 of 2001, respectively), as no particular emergency or extraordinary situations are deemed to exist that would justify derogations from the principle of competition in the name of health protection – with consequent violation also of Article 117, third paragraph, of the Constitution, concerning the latter matter – nor is the reference made by the challenged provision to the state legislation under Law No. 234 of 2021 considered appropriate.

With reference only to Article 240 of Puglia Regional Law No. 42 of 2024, the President of the Council of Ministers also alleged the violation of Article 117, second paragraph, letter l), of the Constitution, "which reserves to the exclusive competence of the State the civil legal system and therefore private law relationships governed by the Civil Code, such as those involving collective labor agreements.”

10.1.– The Puglia Region pleaded the inadmissibility of this latter question, arguing that the challenge lacked specific reasoning, being merely assertive.

This exception is well-founded.

The question, in line with the constant jurisprudence of this Court, is inadmissible, as the appellant limits himself to invoking the parameter without providing a specific and adequate indication of the reasons why there would be a conflict with this parameter (among others, Judgment No. 126 of 2025).

10.2.– The remaining questions, intended to challenge that the foreseen staff integration into the ASL personnel occurs – according to the appellant – outside the ordinary competitive procedures, are unfounded.

The appellant’s premise suffers from a fundamental error in considering the reference made by the challenged regional provision to Article 1, paragraph 268, letter c), of Law No. 234 of 2021 and, specifically, to the phrase "in compliance with current legislation” as irrelevant and improper.

As already recognized in Judgment No. 57 of 2025, in relation to the case of the Ceglie Messapica hospital facility, the foreseen personnel transfer "does not conflict, in fact, with the parameters invoked, because it refers to Article 1, paragraph 268, letter c), of Law No. 234 of 2021, which does not permit stabilization without competition: as clarified by Judgment No. 99 of 2023 of this Court, the relevant procedures must be initiated ‘in compliance with the principles established in matters of public competition.’”

This Court further observed that "[s]uch recruitment method may therefore be legitimately applied by the Region, obviously only where all the prerequisites contemplated by the rule exist: 1) coherence with the three-year personnel needs plan; 2) a subjective limit (regarding the performance of healthcare and socio-healthcare tasks); 3) a time limit (having guaranteed assistance to patients ‘throughout the period between January 31, 2020, and December 31, 2021, and with at least three years of service’). This is the meaning to be attributed to the phrase ‘and in any case in compliance with current legislation,’ evidently referring to the first part of the challenged provision, which renders the latter immune from the alleged constitutional legitimacy defects” (still, Judgment No. 57 of 2025).

Therefore, in light of the considerations already set out in the previous ruling, the regional provision under examination today is exempt from the constitutional legitimacy defects alleged with reference to Articles 97, fourth paragraph, and 117, third paragraph, of the Constitution, the latter concerning the matter of health protection.

11.– With the second set of complaints, the President of the Council of Ministers contends that the regional intervention, with the foreseen transfer of personnel into the ASL staff and the connected financial burden, would conflict with the objectives set in the recovery plan (in particular, that of containing expenditure for healthcare personnel), contravening Article 2, paragraphs 80 and 95, of Law No. 191 of 2009, which prescribes the binding nature of the interventions identified in the plan, requiring regions subject thereto to remove legislative or other provisions that obstruct the full implementation of the programmed interventions, and not to adopt new ones.

The regional legislative intervention, moreover, would not have been communicated in advance to the competent Ministries, nor would it have been coordinated with the operational program for the continuation of the 2024-2026 plan, despite "[t]he evident and significant impact on the Region's financial resources” and the determination of "a tangible increase in healthcare expenditure,” thus realizing an undue modification of healthcare programming, in violation of the prohibition on increasing expenditure for reasons not pertaining to the guarantee of LEA.

Hence, the alleged violation of Article 97, first paragraph, of the Constitution, which requires public administrations to ensure budget balance and public debt sustainability, as well as Article 117, third paragraph, of the Constitution, the latter for violation of the fundamental principles established by the State in the matter of "coordination of public finance.”

11.1.– The Puglia Region pleaded the inadmissibility of the questions thus raised, arguing that no demonstration had been provided of the alleged breach of the constraints imposed by the recovery plan, nor of the real extent of the costs.

However, the exception is unfounded, as, according to the jurisprudence of this Court, "complaints of violation of financial constraints, arising from recovery plans from healthcare deficits, are admissible against provisions that are potentially conducive to increased expenditure, as they affect ‘macro-areas notoriously regulated by plans for recovery from healthcare deficits’ (Judgments No. 89 of 2024 and No. 134 of 2023)” (Judgment No. 57 of 2025).

And in the present case, there is no doubt that sectors falling into this category are at issue (in particular, expenditure for healthcare personnel and the reorganization of territorial care provision, with particular reference to the network of residential assistance for non-self-sufficient elderly persons), so that the verification of the foundation of the claims advanced, which suggest the regional intervention is extraneous to the objectives set in the recovery plan, pertains to the merits (again, Judgment No. 57 of 2025).

11.2.– On the merits, the questions concerning the second set of complaints are also unfounded.

As emerges from the preparatory works for the two challenged regional provisions, the purpose of the legislative intervention under review was to internalize, within the ASLs of Foggia and Lecce, the management of the RSAs in Troia, San Nicandro Garganico, and Campi Salentina, which were "of public ownership from the outset” but until then "managed by private entities under extensions.”

This situation, moreover, – based on the technical report relating to Article 240 of Puglia Regional Law No. 42 of 2024, attached to the preparatory council works – appears to also exist for twelve other public Puglian RSAs, which are in the same condition as those under examination, "all managed by third parties, 2 with current contracts, […] all others under extension for years, despite the regional authorization issued years ago to re-tender the calls, which were never carried out.”

The regional legislator’s intervention, therefore, far from establishing new healthcare facilities – despite the improper title of the provision and its opening – in fact consisted of terminating the extension regime, resulting in the return of the RSAs, always of public ownership, into the functional organization of the relevant ASLs, which now directly provide the services previously supplied by the private manager to the users, thus collecting the share borne by the assisted persons (equal to 50 percent of the current daily rates), previously paid to the latter, while the remaining share remains, as in the past, borne by the regional budget.

This being established, the regional legislation does not entail an undue modification of healthcare programming, nor an "evident and significant impact on the Region's financial resources” due to the alleged "tangible increase in healthcare expenditure,” both of which were presented by the appellant as extraneous to the recovery plan objectives and, as such, prohibited to the respondent.

As already observed in Judgment No. 57 of 2025 regarding the Ceglie Messapica Rehabilitation Center, the RSAs in San Nicandro Garganico, Troia, and Campi Salentina have also long been codified in the public territorial assistance network, as attested by Table A) contained in Annex A to Regional Council Resolution No. 2153 of 2019, so that healthcare programming has not been modified, as asserted by the appellant.

Similarly, the planned internalization of the RSAs in question does not appear to compromise the implementation of the interventions programmed for overcoming the healthcare deficit, but rather falls within the reorganization of the entire territorial care provision, with particular reference to the residential assistance network for non-self-sufficient elderly persons, in which the present facilities are located, an intervention (specifically: GOTER 02.03) contemplated by the 2016-2018 operational program, approved by Regional Council Resolution of February 6, 2018, No. 129 (Operational Program 2016-2018. Plan of actions initiated in the two-year period 2016-2017 and measures to be implemented in 2018).

Finally, regarding the financial repercussions, this Court notes, in line with the frequently cited recent precedent, that, in this case too, services "all certainly falling within the essential levels of assistance” are at stake (traceable to Articles 21 and 30 of the D.P.C.M. of January 12, 2017, concerning "Definition and updating of the essential levels of assistance, pursuant to Article 1, paragraph 7, of Legislative Decree No. 502 of December 30, 1992”), and consequently "of a mandatory nature; so that the challenged regional provisions do not imply further and expanding services compared to those provided by the State.” Reinforcing this argument, already self-sufficient, are the data resulting from the communications of September 25, 2025, and October 3, 2025, respectively from the ASL of Foggia and the ASL of Lecce – attached to the regional brief – attesting to an "effective expenditure saving,” compared to the outsourcing of the service, in terms of management costs, for amounts equal to 411,269.60 euros (RSA Troia), 75,553.95 euros (RSA San Nicandro Garganico), and 352,950.63 euros (RSA Campi Salentina).

Contrary to the appellant’s assertion, therefore, no increase in regional healthcare expenditure following the internalization of the RSAs under review—which occurred in this case on May 1, 2025, for that of Campi Salentina and on May 16, 2025, for those of Troia and San Nicandro Garganico—is demonstrated.

With particular reference to personnel, maintaining the commitment undertaken by the Puglia Region to implement specific measures to ensure the reduction of the overall expenditure relating to this item, this Court has already noted "that the same 2016-2018 operational program in no way excludes the possibility of hiring personnel in order to guarantee the essential levels of assistance” (Judgments No. 57 of 2025 and, similarly, No. 134 of 2023); moreover, although the parties referred in their written submissions to the 2024-2026 operational program, they did not produce it in court, nor does it appear, from the Ministry of Health’s website, to have been adopted, but rather to be still under definition.

In this context, the Puglia Region, given the residue of unused funds amounting to approximately 70 million euros, proceeded to define a new expenditure ceiling for SSR entities with Regional Council Resolution No. 1876 of 2024 (attached to the Region’s briefs), thus excluding any risk of exceeding the aforementioned expenditure ceiling.

In conclusion, therefore, the internalization of the healthcare facilities in question, provided for by the challenged regional legislation, "moves within the economic-financial framework specifically outlined by the recovery plan (in the same vein, Judgment No. 197 of 2024)” (Judgment No. 57 of 2025) and is therefore exempt from the defects alleged by the appellant.

for these reasons

THE CONSTITUTIONAL COURT

reserving decisions on the other questions of constitutional legitimacy raised by the appeals listed above for separate rulings;

joining the proceedings,

1) declares inadmissible the question of constitutional legitimacy of Article 240 of the Law of the Puglia Region of December 31, 2024, No. 42, concerning "Provisions for the preparation of the 2025 budget forecast and the multi-year budget 2025-2027 of the Puglia Region (Regional Stability Law 2025),” raised, with reference to Article 117, second paragraph, letter l), of the Constitution, by the President of the Council of Ministers with appeal No. 12 of 2025;

2) declares unfounded the questions of constitutional legitimacy of Article 26 of the Law of the Puglia Region of November 29, 2024, No. 39 (Financial and Miscellaneous Provisions. Amendment to the Budget Forecast for the fiscal year 2024 and the multi-year period 2024-2026) and Article 240 of Puglia Regional Law No. 42 of 2024, raised, with reference to Articles 97, first and fourth paragraphs, and 117, third paragraph, of the Constitution, by the President of the Council of Ministers with the appeals listed above.

Decided in Rome, at the seat of the Constitutional Court, Palazzo della Consulta, on November 5, 2025.

Signed:

Giovanni AMOROSO, President

Antonella SCIARRONE ALIBRANDI, Rapporteur

Roberto MILANA, Registrar Director

Filed in the Registry on January 29, 2026