The ‘postcode lottery’ of the Italian public health bill analysed with the hierarchy Stochastic Multiobjective Acceptability Analysis

Over the last two decades, due to strong decentralization and widespread budget constraints, the Italian co-payment for health care has become a way to finance public health. This phenomenon has provoked a continuous increase of private costs of public health and an evident regional heterogeneity. As a result, a pervasive spatial inequality of access to public health care is becoming increasingly clear. The aim of this paper is to measure this inequality, mainly determined by the differences among regional co-payment prices. Access, equity, and needs are all part of the phenomenon ‘inequality of access’, and they are difficult to define and measure in health care. For this reason, most of the previously proposed measurement methods have inherent limitations and have prompted us to use an innovative approach focused exclusively on the supply side. In particular, we focus only on the cost of health benefits (co-payment). From a methodological perspective, we use a recent new version of the Stochastic Multiobjective Acceptability Analysis (SMAA), which is a methodology mainly used to build composite indicators of multidimensional phenomena out of the market. In order to deal with the hierarchical structure of the Italian health care system, we use the Hierarchy Stochastic Multiobjective Acceptability Analysis (HSMAA), which takes into account the uncertainty with respect to the weights assigned to the considered criteria, as in the standard SMAA, but also the uncertainty with respect to the weights assigned to the considered sub-criteria. Applying for the first time HSMAA to measure inequality allows us to create a unique index for each region and then to make a classification among them. The results show that, since there are different prices for the same health benefits among different regions, there are strong spatial inequalities in the cost of the Essential Levels of health care in Italy.