L'impatto delle nuove tecnologie sulla sanità: l'efficacia della governance regionale

The aim of the thesis is to show how post-New Public Management interinstitutional cooperation can improve the effectiveness and efficacy of healthcare dematerialisation programs. In order to investigate how cooperative efficacy may improve institutions capability of achieving both managerial (cost saving and efficacy) and substantive purposes (higher quality of healthcare), the thesis focuses on those factors of governance enabling the implementation of successful e-health policies. The first chapter deals with the theoretical framework: inter-istitutional cooperation projects are sought to manage the fiscal crisis of the State, to reduce transaction costs in multilevel governance (Marks, 1993) and to realize the recentralization of services advocated by post-NPM framework (Olsen, 2008; Peters B., 2004; Christensen & Laegreid, 2006). Positive and negative coordination in embedded negotiations (Scharpf, 1994) is presented to overcome the weakness of the traditional partition into hierarchical, market-based and network coordination. Moreover, the thesis emphases the role of knowledge brokers, which facilitate communications in complex networks (Weible, Sabatier, & McQueen, 2009). In the second part, the focus is on Italian e-health policy. From the legal framework analysis, two main aspects emerge: on one hand, the central role played by the Ministry of Economy and Finance, on the other the lacks in the operationalisation of goals about e-prescriptions and Electronic Healthcare Record (EHR). In fact, saving pursed through e-prescriptions is not quantified and in the same way it is not specified how to transform big data collected thanks EHR into any increase in the quality of health assistant, scientific research and governance. At the end of the chapter, Italian Regions are divided into four clusters, according to governance design in digitalization programs as compared to the nature and role played by professional brokers. What is interesting to observe is the peculiarity of the Veneto Region, which has the highest-level of e-prescription in Italy and it is the only case where the broker is a voluntary consortium build by Local Health Authorities and Hospital Trusts (Arsenàl.IT). Because of this reasons, the third chapter goes deep into the analysis of the Veneto case. In particular, an in itinere evaluation according to the realistic policy evaluation approach is developed. The analysis of the policy points out both the coordination system, embedded into a network architecture where Arsenàl.IT plays the broker role, and the ability of general practitioners/ pediatricians and ICT companies to pressure the Region to obtain grants. Then, e-prescription policy is evaluated focusing on effectiveness. Although the excellent results achieved in terms of output (89% of prescriptions for drugs digitalized), the judgement on the main results in terms of outcomes is more ambiguous: the saving allowed by e-prescriptions, equal to 3.5 billion €/ year, is for the moment just potential, because of Region’s difficulties in managing redundancy. On the contrary, the objective fixed by Arsenàl.IT of creating an infrastructural network to link all health workers has been almost achieved, since 99% of general practitioners/ pediatricians and 100% of pharmacies belong to the regional information technology system. Finally, the last chapter illustrates the relationship between the governance solutions implemented in the Italian regions and the results obtained in terms of digitalized prescriptions. Firstly, the correlation index between the amount of e-prescriptions and the system of governance adopted by each Region is calculated. However, the low amount of data and the excessive theoretical simplification underlied to the quantitative approach lead to some deeper considerations. Without demanding completeness, three process variables are discussed to explain why Italian Regions have reached so heterogeneous results in the development of EHR and e-prescriptions: the strategic role played by the intermediaries, the policy legacy and the commitment of key actors.