Michele Zanette

Scale Effects and Expected Savings from Consolidation Policies of Italian Local Healthcare Authorities

BackgroundConsolidation is often considered by policymakers as a means to reduce service delivery costs and enhance accountability.ObjectiveThe aim of this study was to estimate the potential cost savings that may be derived from consolidation of local health authorities (LHAs) with specific reference to the Italian setting.MethodsFor our empirical analysis, we use data relating to the costs of the LHAs as reported in the 2012 LHAs’ Income Statements published within the New Health Information System (NSIS) by the Ministry of Health. With respect to the previous literature on the consolidation of local health departments (LHDs), which is based on ex-post-assessments on what has been the impact of the consolidation of LHDs on health spending, we use an ex-ante-evaluation design and simulate the potential cost savings that may arise from the consolidation of LHAs.ResultsOur results show the existence of economies of scale with reference to a particular subset of the production costs of LHAs, i.e. administrative costs together with the purchasing costs of goods (such as drugs and medical devices) as well as non-healthcare-related services.ConclusionsThe research findings of our paper provide practical insight into the concerns and challenges of LHA consolidations and may have important implications for NHS organisation and for the containment of public healthcare expenditure.

Larger is Better: the Scale Effects of the Italian Local Healthcare Authorities Amalgamation Program

Consolidation is often considered as a means to lower service delivery costs and enhance accountability. This paper uses a prospective evaluation design to derive estimates of the potential cost savings that may arise from Local Healthcare Authorities (LHAs) amalgamation process, which is concerning the Italian National Health System. We focus specifically on cost savings due to scale economies with reference to a particular subset of the production costs of the LHAs, i.e. the administrative costs together with the purchasing costs of both goods as well as non-healthcare related services. Our results demonstrate the existence of economies of scale linked to the size of the LHA population. Hence, the decision to reduce the number of LHAs may result in larger local health authorities that are more cost efficient, especially when the consolidation process concerns merging a large number of LHA.

A Procedure for the Ex-Ante Assessment of Compulsory Municipal Amalgamation Programs

The aim of the paper is to develop a procedure that allows policy makers to make an ex-ante assessment of a general compulsory amalgamation policy, providing quantitative indications about the possible financial effects. The amalgamation of small municipalities is a widespread practice all over the world. This policy is based on the assumption that local public service provision is characterized by economies of scale and economies of scope. However, population size is not the only determinant of economies of scale, which depend on many other factors. For these reasons, the expected effects of any amalgamation program are uncertain, and ex-post empirical analyses are unable to offer unambiguous indications to policy makers since all programs differ. After a brief discussion of the relevant issues concerning amalgamation, we present the procedure used to simulate the economics and administrative effects of a general compulsory amalgamation policy. The procedure is tested with reference to the municipalities of Veneto, a region of Italy and we provide the results of a number of simulations under alternative amalgamation policies. The main result is that amalgamation policies based only on the a priori rule that small municipalities should merge may be very inefficient because the expenditure reduction following an amalgamation policy may depend to a considerable extent on other territorial and socio-economic characteristics of the municipalities involved.

Standard Spending Needs of Italian Municipalities

Standard spending needs of municipalities, a crucial aspect of fiscal federalism, should be computed under some conditions: that municipalities have the same efficiency, that citizens have the same preferences, and, especially, that local governments are equal with regard to some «non structural» characteristics. The fitted values obtainable from the estimate of an expenditure function do not satisfy these conditions. Standard spending needs are better represented by conditional expected values, which are obtained by sterilizing differences in non structural determinants of municipality expenditures, like government grants. To compute spending needs we define two standard levels: an «average» standard and a «minimal» standard, which is defined as the minimum amount of resources that allows municipalities to provide a sufficient level of services. The method is applied to 2007 data of Italian municipalities.