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 TOC \o "1-3" \h \z \u  HYPERLINK \l "_Toc327264009" Abstract  PAGEREF _Toc327264009 \h 3
 HYPERLINK \l "_Toc327264010" 1. Introduction  PAGEREF _Toc327264010 \h 3
 HYPERLINK \l "_Toc327264011" 2. Motivation and brief literature  PAGEREF _Toc327264011 \h 5
 HYPERLINK \l "_Toc327264012" 3. Italian's health care system: provision of care and financing  PAGEREF _Toc327264012 \h 8
 HYPERLINK \l "_Toc327264013" 4. Regional differences  PAGEREF _Toc327264013 \h 9
 HYPERLINK \l "_Toc327264014" 4.1. Health outcomes differences  PAGEREF _Toc327264014 \h 9
 HYPERLINK \l "_Toc327264015" 4.2. Health inputs differences  PAGEREF _Toc327264015 \h 11
 HYPERLINK \l "_Toc327264016" 4.3. Some socio-economic and demographic differences  PAGEREF _Toc327264016 \h 15
 HYPERLINK \l "_Toc327264017" 5. Data and variables  PAGEREF _Toc327264017 \h 18
 HYPERLINK \l "_Toc327264018" 6. Methodology of analysis: analytical framework  PAGEREF _Toc327264018 \h 20
 HYPERLINK \l "_Toc327264019" 6.1. DEA model  PAGEREF _Toc327264019 \h 22
 HYPERLINK \l "_Toc327264020" 6.2. Censored panel analysis  PAGEREF _Toc327264020 \h 23
 HYPERLINK \l "_Toc327264021" 6.3. Cluster analysis  PAGEREF _Toc327264021 \h 23
 HYPERLINK \l "_Toc327264022" 7. Results  PAGEREF _Toc327264022 \h 25
 HYPERLINK \l "_Toc327264023" 7.1. DEA slacked model results  PAGEREF _Toc327264023 \h 25
 HYPERLINK \l "_Toc327264024" 7.2 Censored econometric results  PAGEREF _Toc327264024 \h 29
 HYPERLINK \l "_Toc327264025" 8. Discussion  PAGEREF _Toc327264025 \h 30
 HYPERLINK \l "_Toc327264026" Discussion of regional differences  PAGEREF _Toc327264026 \h 30
 HYPERLINK \l "_Toc327264027" Discussion of DEA model results  PAGEREF _Toc327264027 \h 32
 HYPERLINK \l "_Toc327264028" Discussion of second stage analysis  PAGEREF _Toc327264028 \h 34
 HYPERLINK \l "_Toc327264029" 9. Conclusion and such possible policy implications  PAGEREF _Toc327264029 \h 36
 HYPERLINK \l "_Toc327264030" References  PAGEREF _Toc327264030 \h 38

Health outcomes and mix inefficiency: a case of Italian’s Regional Health Care Systems
(Preliminary version)
This paper critically analyzes the relative efficiency in the Italian’s regional collective health outcomes using HFA health data. The empirical literature on health economics often use OECD sample for efficient relative comparison of Health Systems, focusing on the Italian’s regional health care system level. Can it be that a health system or regional health care system is technical efficient but spending inefficient if the use of resources is expensive or vice versa (for example when the prices are very low and reducing, can use more resources than necessary relatively compared at the output level). So technically, efficiency is a very important dimension of health system performance, and measurement about nonparametric method is very useful when there is multi-objectives contest in addition to when it is difficult to individuate relation between output and input, such as the case of Regional Health Care Systems. DEA analysis reveals, that on average on the period analyzed, 66,2% level of efficiency with potential efficiency gains of 33,8% in ten years. Some fully efficient Regional Health Care System (RHCS) are Valle D'Aosta, Friuli V.G., Trentino A.A. and Liguria. Regional differences analysis show that on average life expectation at 0 years, for male and female is increasing, whereas general rate of mortality is decreasing with significant differences between regions, and physical resources have different path, not more different between regions. The possible influences of the demographics-socio-economic and lifestyle variables on the inefficiency, analyzed in econometric framework, reveals that for such variables the influence is of improved for some. For instance, the ratio of public health care spending on the entire health care spending and worsening for other variable such as day average cigarette, whereas for other variables is dubious the influences. It is important to use precaution interpreting results for policy indication.
Keywords: health production, health care regional differences, health care system performance and efficiency, DEA, panel Tobit
Health outcomes and mix inefficiency: a case of Italian’s Regional Health Care Systems
1. Introduction
Measurement of public sector performance, when they offer fundamental service such as health, transportation, instruction, justice among others, is an important issue in the economic debate, for researcher and for policy maker. The magnitude of public or private provision has a direct impact on the wellbeing and is vital for the economic development and growth. In this paper measurement of performance issue is considered in terms of relative efficiency of regional health care systems in Italy, where is principally public financed. Question remains irrelevant even when state of country’s overall health, in terms of life expectancy and rate of mortality, are in significant improvement. But we must not overlook the impact of risk factor, individual and collective, as the quality of life, individual lifestyle and socio-economic factors on the health status, directly, and therefore the level of health resources available for obtain the health status of population. So this paper to try consider the influence of such factor on the inefficiency of regional health care systems, later relative efficiency is derived for each regional health care system. In this direction Retzlaff et al (2004) considers technical efficiency in the provision of aggregate health status of the population in OECD country, and use results for policy indication. The present work in the health care system level of Italy is ordered at three levels of government; they are the central, local level, and regional. The central level constitute of the Ministry of Health, which oversee the National Health Fund, abolished by Legislative Decree 56/2000 and to be replaced by various regional taxes. For this reason, the Central level is responsible for fixing minimum level of care (LEA) and also fixing the National Health Plans. At regional level, governments have the responsibility of pursuing and implementing the leading national objective developed by the National Health Plan and to guarantee a package of benefits (LEA) at the population trough local health units (ASL) and public and private credited hospitals. Regional planning activities of health care, organize supply in relation to population needs, monitoring the quality, appropriateness and efficiency of the services provided and are responsible for legislative and administrative functions. At local level they operate four different categories of institutions: local health units (ASL), National Institutes for Scientific research (IRCCS), public hospital trusts and private accredited health care providers. Because of decentralization and devolution, the regional health care system has become the most important sub-level public sector for Region. So the Italian's Regions are not simply centers of spending of the central resources, indeed, Regions manage, organize and finance their own RHCS. In view of this fact that there is a contest then, how efficiently do different Region use their input resource to achieve their health outcome is a central question? By identifying the inputs it is probable to determine how technically efficient (TE) a Region is at health production. In this work is clear that the health production in a population is a multifactor and multifaceted issue. In fact, health aggregate population depends to socio-economic factors such as education, income, working conditions, lifestyle (for example, consumption of tobacco and alcohol, physical activity) and preference, psychological factors (stress, isolation etc), biological factors (adrenalin, and hypertension etc.) latest government policies (economic, welfare, health, housing and transport).
This paper presents some advantage respect other work. First, a DEA model for slack measurement is used; to gain information about the single input reduced and not only input proportional reduction. Second, is that a health regional system level of analysis and not at level of health care system and thirdly, consider the influence of regional difference in terms of socio-economic variables on the regional health care efficiency, useful for possible policy indications.
2. Literature Review
The health of the population is one of most vital services provided by Italian's Regions. The RHCS (Regional Health Care System/Sistemi Sanitari Regionali), in general sense, it is efficient in health production that constitute it, it also provide health using the best possible resources. The major question is whether RHCS could obtain results by spending less or with is spending level and obtain more, or could it be spending causes inefficient. According to OECD, the total spending on health in GDP percentage was in Italy 8.1% in 2000 and 9.5% in 2009, whereas public spending on health percentage total spending on health was 72.5% in 2000 and 77.3% in 2009. Professionally active physicians’ density per 1000 populations was 4.2 in 2000 and 2009; hospital beds density per 1000 population was 4.7 in 2000 and 3.8 in 2008. One unit or regional health system, although have high spending and are inefficient for this point of view, because of use of very expensive input (for example Anderson et al, (2003) find that USA spending differential are determined by high ...
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