Processo di decentramento del SSN ed evoluzione dell’equità interregionale nell’assistenza sanitaria nel periodo 2001-2012

Journal title MECOSAN
Author/s Antonio Nuzzo, Flavia Carle, Eugenio Anessi Pessina
Publishing Year 2019 Issue 2018/108 Language Italian
Pages 26 P. 9-34 File size 501 KB
DOI 10.3280/MESA2018-108002
DOI is like a bar code for intellectual property: to have more infomation click here

Below, you can see the article first page

If you want to buy this article in PDF format, you can do it, following the instructions to buy download credits

Article preview

FrancoAngeli is member of Publishers International Linking Association, Inc (PILA), a not-for-profit association which run the CrossRef service enabling links to and from online scholarly content.

The policies pursued both at the international and national levels have brought to the fore the concept of governance decentralization of health-care systems. In Italy, in particular, with the approval of legislative decree n. 56/2000 on fiscal federalism and the amendments to Title V of the Constitution (Const. Law n. 3/2001), the Regions have obtained wider political, administrative, organizational and management competencies also in health care. At the international level, several studies have examined the issue of equity in a decentralized health-care system. In the Italian context, this also involves the provision of essential levels of health care (LEAs) across Regions. Equity is a constitutional principle, pursued by the central level and monitored through the set of indicators of the "LEA Grid" (Griglia LEA). Starting from the "LEA Grid" indicators, through a multidimensional analysis by principal components, the study analyzes the evolution of inter-regional equity in the provision of health care (prevention, hospital care, outpatient care) between 2001 and 2012, when the process of health-care decentralization became more established. In line with the international literature, this analysis shows a significant inter-regional heterogeneity. In particular, it highlights: 1) an interregional differentiation with respect to the principal components defined "vaccination coverage", "hospital care performance" and "outpatient care for the disabled"; 2) a persistent differentiation in "hospital care" between central-northern and southern regions; 3) a negative trend for the autonomous regions and provinces both in the provision of "hospital care" and "vaccination coverage". The results of the study, innovative for equity dimensions explored and data available, justify the central government’s intervention as guarantor of territorial equity with respect to the provision of health care.

Keywords: Decentralisation, regions, National Health Service, equity, inter-regional differentiation, essential levels of health care.

  1. Anessi-Pessina E., Cantu E. (2006). Whither managerialism in the Italian National Health Service? Int J Health Plan Manage 2006;21:327-55.
  2. Bankauskaite V., Dubois HFW., Saltman RB. (2007). Patterns of decentralization across European health systems. In: Saltman R.B., Bankauskaite V., Vrangbaek K., editors. Decentralization in health care. Strategies and outcomes. European observatory on health systems and policies series. Open University Press.
  3. Busse R., Stargardt T., Schreyogg J. (2005). Determining the benefit basket of the Statutory Health Insurance scheme in Germany: methodologies and criteria. Eur J Health Econ.
  4. Cantarero D., Pascual M. (2008). Analysing the impact of fiscal decentralization on health outcomes: empirical evidence from Spain. Appl Econ Lett. DOI: 10.1080/13504850600770913
  5. Carrieri V. (2008). Disuguaglianze di salute e condizioni socio-economiche in Italia: esiste una questione meridionale? Politiche Sanitarie. DOI: 10.1706/349.4068.
  6. Caruso E., Dirindin N. (2006). La sanità nel 2005: il rigore finanziario tra adempimenti, allarmi e crociate per la salute. il Mulino: Rapporto sulla finanza pubblica; 2006. pp. 101-27.
  7. Corchia C., Mastroiacovo R., Lanni V., Grimaldi G., Scarano, Baronciani D. (1995). Social and geographical inequalities in prenatal care in Italy. Prenatal Diagnosis.
  8. Corchia C., Orzalesi M. (2007). Geographic variations in outcome of very low birth weight infants in Italy. Acta Paediatrica, 96, 35-38.
  9. Costa G., Marinacci C., Caiazzo A., Spadea T. (2003). Individual and contextual determinants of inequalities in health: the Italian case. International Journal of Health Services. DOI: 10.2190/AM8RK0DY-F7PM-3RNP
  10. Costa-i-Font J., Turati G. (2016). Regional Health Care Decentralization in Unitary States: Equal Spending, Equal Satisfaction? LSE ‘Europe in Question’ Discussion Paper Series No. 113/2016.
  11. Culyer A. (2001). Equity: some theory and its policy implications. Journal of Medical Ethics.
  12. De Vonderweid U., Spagnolo A., Corchia C., Chiandotto V., Chiappe S., Chiappe F. et al. (1994). Italian multicentre study on very low-birth-weight babies. Neonatal mortality and two-year outcome. Acta Paediatr 1994;83:391-6.
  13. Di Bartolomeo S., Valent F., Rossi C., Beltrame F., Anghileri A., Barbone F. (2008). Geographical differences in mortality of severely injured patients in Italy.
  14. Di Novi C., Piacenza M., Robone S., Turati G. (2015). How does fiscal decentralization affect within-regional disparities in well-being? Evidence from health inequalities in Italy. University of York.
  15. Ebel R., Yilmaz S. (2001). On the Measurement and Impact of Fiscal Decentralisation. Paper presented on the Symposium of Public Finance in developing countries: essays in honour of Richard M. Bird.
  16. Fattore G. (1999a). Clarifying the scope of Italian NHS coverage: is it feasible? Is it desirable? Health Policy 1999;50:123-42. DOI: 10.1016/S0168-8510(99)00068-8
  17. Fattore G. (1999b). Cost-containment and reforms in the Italian National Health Service. In: Mossialos E., Le Grand J., editors. Health care and cost containment in the European Union. Ashgate: Aldershot; 1999, pp. 513-46.
  18. Ferrera M. (1995). The rise and fall of democratic universalism: health care reform in Italy, 1978-1994. J Health Politics Policy Law 1995;20(2):275-302. DOI: 10.1215/03616878-20-2-275
  19. France G. (2006) Federalismi e sanità. Istituto di studi sui sistemi regionali federali e sulle autonomie. Consiglio Nazionale delle Ricerche; (A. Giuffre).
  20. France G., Taroni F. (2005). The evolution of health-policy making in Italy. J Health Politics Policy Law 2005;30 (February-April (1–2)). DOI: 10.1215/03616878-30-1-2-169
  21. France G., Taroni F., Donatini A. (2005). The Italian health-care system. Health Econ 2005;14:S187–202.
  22. Fusco M., Pezzi A., Benatti P. et al. (2010). Clinical features and colorectal cancer survival: an attempt to explain differences between two different Italian regions. Eur J Cancer. 2010;46:142–149. [PubMed].
  23. Granaglia E., Compagnoni V. (2006). Disuguaglianze sanitarie e Mezzogiorno. Mimeo, DPS, MPS. Ministero dell’Economia e delle Finanze, Roma.
  24. Hurley J. (2001). Ethics, economics, and public financing of health care. Journal of Medical Ethics.
  25. Jimenez-Rubio D. (2011). The impact of decentralization of health services on health outcomes: evidence from Canada. Applied Economics, Taylor & Francis. DOI: 10.1080/00036841003742579
  26. Jimenez-Rubio D., Smith P., Van Doorslaer E. (2008) Equity in health and health care in a decentralized context: evidence from Canada. Health Econ.
  27. Khaleghian P. (2004). Decentralization and public services: The case of immunization. Social Science and Medicine.
  28. Lauria L., Saporito M. (2004). Comparison of stillbirth and neonatal mortality in two Italian regions: Lombardia and Campania. --
  29. Magnussen J., Hagen T.P., Kaarboe O.M. (2007). Centralized or decentralized? A case study of Norwegian hospital reform. Soc Sci Med 2007; 64 (May (10)):2129–37.
  30. Magnussen J., Tediosi F., Mihalyi P. (2007). Effect of decentralization and recentralization on economic dimensions of health systems. In: Saltman R.B., Bankauskaite V., Vrangbaek K., editors. Decentralization in health care. Strategies and outcomes. European observatory on health systems and policies series. Open University Press.
  31. Maino F. (2001). La politica sanitaria. Bologna: il Mulino.
  32. Masseria C., Giannoni M. (2010). Equity in access to health care in Italy: a disease-based approach. European Journal of Public Health.
  33. Masseria C., Paolucci F. (2005). Equità nell’accesso ai ricoveri ospedalieri in Europa e in Italia. Quaderni Acp. Ministero della Salute, Ufficio VI – Direzione
  34. Generale Programmazione Sanitaria (2014). “Analisi spazio-temporale 2001-2012 degli indicatori della Griglia LEA, trend 2001-2012” -- (
  35. taliano&id=3990&menu=lea&idP=1302). Ministero della Salute, Ufficio VI – Direzione Generale Programmazione Sanitaria (2019). “Mantenimento nell’erogazione dei LEA nell’ambito della verifica adempimenti 2017” -- (
  36. Montero-Granados R., de Dios-Jimenez J., Martin J. (2006). Decentralization and convergence in health among the provinces of Spain (1980-2001). Social Science and Medicine.
  37. Piacenza M., Turati G. (2014). Does Fiscal Discipline towards Sub-national Governments Affect Citizens’ Well-being? Evidence on Health. Health Economics, 23(2): 199-224.
  38. Robalino D.A., Picazo O.F., Voetberg A. (2001). Does fiscal decentralization improve health outcomes? Evidence from a cross country analysis. Policy Research Working Paper No. 2565, Washington DC World Bank. DOI: 10.1596/1813-9450-2565
  39. Rondinelli D.A. (1983). Decentralization in developing countries. Staff working paper. Washington (DC): World Bank.
  40. Saltman R.B. (2008). Decentralization, re-centralization and future European health policy. Eur J Public Health;18(April (2)):104-6.
  41. Saltman R.B., Bankauskaite V., Vrangbaek K. (2006). Conceptualizing decentralization in health care systems: a functional perspective. Health Econ Policy Law 2006; 1:127–47. DOI: 10.1017/S1744133105001209
  42. Soto V.E., Farfan M.I., Lorant V. (2012). Fiscal decentralization and infant mortality rate: the Colombian case. Soc Sci Med. 2012 May;74(9):1426-34. Epub 2012 Feb 27.
  43. Tarazona M. (2010). Il processo di decentramento della sanità: il caso della Spagna. Convegno su Federalismo e diritti di cittadinanza nel modello mediterraneo, Napoli.
  44. Tediosi F., Gabriele S., Longo F. (2009). Governing decentralization in health care under tough budget constraints: What can we learn from the Italian experience? Health Policy 90 (2-3): 303-312.
  45. Toth F. (2014). How health care regionalization in Italy is widening the North-South gap. Health Economics, Policy and Law, 9 (3): 231-249. DOI: 10.1017/S1744133114000012
  46. Viceconte N. (2011). L’evoluzione del sistema di finanziamento del servizio sanitario nazionale tra federalismo “promesso” ed esigenze di bilancio. Il regionalismo italiano dall’Unita alla Costituzione e alla sua riforma, Vol. II. Milano: Giuffre.
  47. Wolman H. (1990). Decentralization, local government, and markets: towards a post-welfare agenda. Oxford: Clarendon Press.
  48. Yee E. (2001). The Effects of Fiscal Decentralization on Health Care in China. Princeton University.
  49. Zanola R. (2010). Public goods versus publicly provided private goods in a two-class economy. Working paper n. 13 Dipartimento di Politiche Pubbliche e Scelte Collettive – POLIS.
  50. Zhong H. (2010). The impact of decentralization of health care administration on equity in health and health care in Canada. Int J Health Care Finance Econ.
  51. Wagstaff A., Van Doorslaer E. (1993). Equity in the finance and delivery of health care: concepts and definitions. In: Van Doorslaer E., Wagstaff A., Rutten F., eds, Equity in the finance and delivery of health care: an international perspective. European Community Health Services Research Series No. 8. Oxford, Oxford University Press.

  • Measuring Regional Performance in the Italian NHS: Are Disparities Decreasing? Silvia Bruzzi, Enrico Ivaldi, Marta Santagata, in Social Indicators Research /2022 pp.1057
    DOI: 10.1007/s11205-021-02775-8
  • Il contributo del management alla definizione della strategia di decentramento del Servizio Sanitario: il caso del Servizio Sanitario Tunisino Niccolò Persiani, Martina Giusti, Maria Jose Caldes, Afef Hagi, in MECOSAN 122/2022 pp.85
    DOI: 10.3280/mesa2022-122oa14619

Antonio Nuzzo, Flavia Carle, Eugenio Anessi Pessina, Processo di decentramento del SSN ed evoluzione dell’equità interregionale nell’assistenza sanitaria nel periodo 2001-2012 in "MECOSAN" 108/2018, pp 9-34, DOI: 10.3280/MESA2018-108002