Regionalization of the public health system and new governance models for healthcare: the stroke network case in Italy

Background: In the 1990s, Italy enacted a drastic reform of the public administration system, giving local governments (regions) unprecedented autonomy in public service management, including healthcare. This shift in responsibilities resulted in a lack of consistency in budget performance and quality of medical care in the regional health systems. Purpose: This article describes the outcomes of a 2009 study into the reasons for the regional differences in implementation of "stroke networks" in Italy. Strokes represent one of the most important health issues for Italy. They are the primary causes of permanent disability, the second highest cause of dementia, and (in Italy) the third highest cause of mortality. Evidence shows that early diagnosis and delivery of treatment in specialized stroke units, including rehabilitation therapy, can reduce the risks of death and disability. Nevertheless, there are significant differences and delays in the implementation of such practices. To understand the reasons for the delays, measures were examined, including decision makers' agendas, regional budget limitations, organizational delays, structural complexity, competition over scarce resources, power structure differences, and informal practices. Methods: The study consisted of 52 in-depth interviews and six focus groups involving 62 people (total = 114 interviewees) and addressing key actors in the health systems from six Italian regions. In accordance with Italian regulations and research practices, the present sociological study did not require the approval by an Ethical Committee, since it did not involve minors or subjects who might be injured, coerced, or those who necessitate an informed consent. Results: This study outlines five main models of management and shows how competition with private hospitals, internal rivalries involving professionals and medical sectors, expenditure restraints, and a lack of well-trained personnel represent the main obstacles to the development and operation of stroke units. Policy Implications: Network implementation should be framed within the culture and standards of the broader social and health context. Social networks should be central to the system of care, targeting long-term health issues associated with strokes. There is also a need to decrease competition and increase collaboration among the stakeholders. Finally, the relation between hospitals, care services, and regional administrations requires improvement.