Does neighbours' grass matter? Testing spatial dependent heterogeneity in technical efficiency of Italian hospitals.

Testing for spatial dependent heterogeneity in hospital technical efficiency is crucial for separating spatial issues from the effects of regional institutional factors. We apply the Spatial Stochastic Frontier Analysis for studying the presence of spatial dependence by using novel data on Italian hospitals. This approach provides both a robust estimation of hospital technical efficiency and a careful assessment of spatial and regional issues. We find empirical support for the idea that regional and institutional factors are more important than neighbouring effects when looking at heterogeneity in hospital technical efficiency across Italy. The relevance of the regional organization of the Italian hospital system can justify our results. We also discuss the limitations of our analysis and provide sensitivity checks.

Convergence, decentralization and spatial effects: An analysis of Italian regional health outcomes.

Fiscal decentralization has been a key component of many health sector reforms. Nevertheless, the actual effects of greater financial accountability by regional governments on reducing geographical health disparities are still debatable. The existing empirical literature is highly fragmented, focusing either on the effect of fiscal decentralization on health outcomes (without considering convergence) or on the convergence process in health (without considering decentralization). This paper aims to make a step forward by disentangling the role played by fiscal decentralization on the convergence dynamics of infant mortality rate and life expectancy at birth, considering also spatial effects. To this purpose, a panel of 20 Italian regions over the period 1996-2016 is investigated. For both our health outcomes, the results point towards no reduction in dispersion levels but evidence of a "catching-up" effect among regions. Exploiting the panel dimension of the data, fiscal decentralization seems to favour the rate of convergence of the Italian regions. However, the fiscal decentralization-growth rate relationship is sensitive to the regional level of health outcome: once high performance levels are reached, more consistent improvements require giving up a certain degree of fiscal accountability. Finally, spatial interactions appear statistically relevant for explaining the regional convergence process.

On the role of environmental corruption in healthcare infrastructures: An empirical assessment for Italy using DEA with truncated regression approach.

OBJECTIVES: This paper investigates empirically whether the institutional features of the contracting authority as well as the level of 'environmental' corruption in the area where the work is localised affect the efficient execution of public contracts for healthcare infrastructures. METHODS: A two-stage Data Envelopment Analysis (DEA) is carried out based on a sample of Italian public contracts for healthcare infrastructures during the period 2000-2005. First, a smoothed bootstrapped DEA estimator is used to assess the relative efficiency in the implementation of each single infrastructure contract. Second, the determinants of the efficiency scores variability are considered, paying special attention to the effect exerted by 'environmental' corruption on different types of contracting authorities. RESULTS: Our results show that the performance of the contracts for healthcare infrastructures is significantly affected by 'environmental' corruption. Furthermore, healthcare contracting authorities are, on average, less efficient and the negative effect of corruption on efficiency is greater for this type of public procurers. CONCLUSIONS: The policy recommendation coming out of the study is to rely on 'qualified' contracting authorities since not all the public bodies have the necessary expertise to carry on public contracts for healthcare infrastructures efficiently.

Does fiscal decentralization improve health outcomes? Evidence from infant mortality in Italy.

Despite financial and decision-making responsibilities having been increasingly devolved to lower levels of government worldwide, the potential impact of these reforms remains largely controversial. This paper investigates the hypothesis that a shift towards a higher degree of fiscal autonomy of sub-national governments could improve health outcomes, as measured by infant mortality rates. Italy is used as a case study since responsibilities for healthcare have been decentralized to regions, though the central government still retains a key role in ensuring all citizens uniform access to health services throughout the country. A linear fixed-effects regression model with robust standard errors is employed for a panel of 20 regions over the period 1996-2012 (340 observations in the full sample). Decentralization is proxied by two different indicators, capturing the degree of decision-making autonomy in the allocation of tax revenues and the extent to which regions rely on fiscal transfers from the central government. The results show that a higher proportion of tax revenues raised and/or controlled locally as well as a lower transfer dependency from the central government are consistently associated with lower infant mortality rates, ceteris paribus. The marginal benefit from fiscal decentralization, however, is not constant but depends on the level of regional wealth, favouring poorest regions. In terms of policy implications, this study outlines how the effectiveness of decentralization in improving health outcomes is contingent on the characteristics of the context in which the process takes place.

Reimbursement systems and quality of hospital care: an empirical analysis for Italy.

There is an ongoing debate about the effect of different reimbursement systems on hospital performance and quality of care. The present paper aims at contributing to this literature by analysing the impact of different hospital payment schemes on patients' outcomes in Italy. The Italian National Health Service is, indeed, a particularly interesting case since it has been subject to a considerable decentralization process with wider responsibilities devolved to regional governments. Therefore, great variability exists in the way tariffs are used, as Regions have settled them in accordance with the characteristics of health care providers. An empirical analysis of the Italian hospital system is carried out using data from the National Program for Outcome Assessment on mortality and readmissions for Acute Myocardial Infarction (AMI), Congestive Heart Failure (CHF), stroke and Chronic Obstructive Pulmonary Diseases (COPD) in the years 2009-2010. The results show that hospitals operating in Regions where prospective payments are used more extensively are generally associated with better quality of care.

Geographical variation of unmet medical needs in Italy: a multivariate logistic regression analysis.

BACKGROUND: Unmet health needs should be, in theory, a minor issue in Italy where a publicly funded and universally accessible health system exists. This, however, does not seem to be the case. Moreover, in the last two decades responsibilities for health care have been progressively decentralized to regional governments, which have differently organized health service delivery within their territories. Regional decision-making has affected the use of health care services, further increasing the existing geographical disparities in the access to care across the country. This study aims at comparing self-perceived unmet needs across Italian regions and assessing how the reported reasons - grouped into the categories of availability, accessibility and acceptability - vary geographically. METHODS: Data from the 2006 Italian component of the European Union Statistics on Income and Living Conditions are employed to explore reasons and predictors of self-reported unmet medical needs among 45,175 Italian respondents aged 18 and over. Multivariate logistic regression models are used to determine adjusted rates for overall unmet medical needs and for each of the three categories of reasons. RESULTS: Results show that, overall, 6.9% of the Italian population stated having experienced at least one unmet medical need during the last 12 months. The unadjusted rates vary markedly across regions, thus resulting in a clear-cut north-south divide (4.6% in the North-East vs. 10.6% in the South). Among those reporting unmet medical needs, the leading reason was problems of accessibility related to cost or transportation (45.5%), followed by acceptability (26.4%) and availability due to the presence of too long waiting lists (21.4%). In the South, more than one out of two individuals with an unmet need refrained from seeing a physician due to economic reasons. In the northern regions, working and family responsibilities contribute relatively more to the underutilization of medical services. Logistic regression results suggest that some population groups are more vulnerable than others to experiencing unmet health needs and to reporting some categories of reasons. Adjusting for the predictors resulted in very few changes in the rank order of macro-area rates. CONCLUSIONS: Policies to address unmet health care needs should adopt a multidimensional approach and be tailored so as to consider such geographical heterogeneities.