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Purpose: This study aimed to compare technical efficiency of general practice (GP) delivered by the twenty Regions of Italy's decentralized healthcare system and to determine if it was affected by contextual factors. Methods: First, we calculated the Regional efficiency scores by means of Data Envelopment Analysis. Then we carried out a regression analysis to investigate the influence of contextual factors on the efficiency in the provision of GP services. Results: Six Northern Regions were identified as efficient using the best combinations of general practitioners to deliver a given level of GP outcomes. Compared with peer benchmarks, inefficient Regions used more (on-call and regular) general practitioners with important underproductions of outputs (e.g. avoidable hospitalizations). The regression analysis showed a negative relationship between efficiency and the Regional total health care expenditures as percentage of its Gross Domestic Product. Discussion: Improving efficiency of GP services delivery is likely to result in reduced health expenditures. Since there is a general tendency in Europe to decentralize governmental systems of countries and Italy can be seen as an extreme example of this trend, we consider our findings of high relevance for international comparative studies on performance of primary care systems. (C) 2012 Elsevier Ireland Ltd. All rights reserved

Objectives This study aimed at assessing public health residents’ perceived health system governance (HSG) training needs and to define a competency framework for “good governance” to improve Public Health physicians’ curricula. Methods A questionnaire was administered to all Italian medical residents on postgraduate courses in Hygiene and Preventive medicine. Twenty-five (78.1 %) of the 32 Italian Schools of Public Health and 299/535 residents (55.9 %) took part in this survey. The public health governance competency framework was developed from roles and responsibility at different levels of governance in the Italian Health System context. Results The questionnaire revealed that residents felt the need for more training on all the proposed HSG-related topics. Different governance functions, strategic planning, operational planning, and operational programming were considered when defining roles and responsibilities. Conclusions More efforts should be made to provide organic training plans tailored to the needs of local and national health system. The competencies framework for good governance could be useful for planning professional training in both the academic and the health system settings.

Italy is the sixth largest country in Europe and has the second highest average life expectancy, reaching 79.4 years for men and 84.5 years for women in 2011. There are marked regional differences for both men and women in most health indicators, reflecting the economic and social imbalance between the north and south of the country. The main diseases affecting the population are circulatory diseases, malignant tumours and respiratory diseases. Italy's health care system is a regionally based national health service that provides universal coverage largely free of charge at the point of delivery. The main source of financing is national and regional taxes, supplemented by copayments for pharmaceuticals and outpatient care. In 2012, total health expenditure accounted for 9.2 percent of GDP (slightly below the EU average of 9.6 percent). Public sources made up 78.2 percent of total health care spending. While the central government provides a stewardship role, setting the fundamental principles and goals of the health system and determining the core benefit package of health services available to all citizens, the regions are responsible for organizing and delivering primary, secondary and tertiary health care services as well as preventive and health promotion services. Faced with the current economic constraints of having to contain or even reduce health expenditure, the largest challenge facing the health system is to achieve budgetary goals without reducing the provision of health services to patients. This is related to the other key challenge of ensuring equity across regions, where gaps in service provision and health system performance persist. Other issues include ensuring the quality of professionals managing facilities, promoting group practice and other integrated care organizational models in primary care, and ensuring that the concentration of organizational control by regions of health-care providers does not stifle innovation.