The distributional impact of health public expenditure in Italian regions: what happens when cost-effectiveness and quality matter?

Abstract

We evaluate the implications of in-kind health transfers on household income distribution in Italy, factoring in the quality of government-provided healthcare in different regions (which are responsible for health policy). The novelty of this approach is that we explicitly acknowledge differences in the value of in-kind transfers resulting from cross-regional variations in service quality. The aim of this paper is twofold. First we adopt a fiscal federalism approach to assess the distributional implications of adding health public expenditure to the disposable income of Italian households and we compare the distributional results across regions. We then take a yardstick competition approach to evaluate the distributional implications of accounting for the quality and efficiency of services. To analyze the distributional impact of health public expenditure, we show the difference of the Gini index between final income and disposable income for each region and the progressivity index (Kakwani index). The re-ranking effect and the average in-kind benefit rate (that is the ratio of total in-kind transfers to disposable income) are also computed. Our analysis provides convincing evidence that when health services are evaluated at production cost, in-kind benefits reduce overall inequality on the distribution of disposable income. However, this effect is seen to be lower when the yardstick competition approach is applied to account for quality and cost-effectiveness, and, more importantly, it shows a geographical pattern.