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Open Access 09-05-2024 | Original Paper

Do institutions matter for citizens’ health status? Empirical evidence from Italy

Authors: M. Alessandra Antonelli, Giorgia Marini

Published in: The European Journal of Health Economics

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Abstract

This paper investigates the role of institutional quality in explaining cross-regional variation in population health status in Italy. We first introduce a composite Regional Health Status Indicator summarizing life expectancy, mortality and morbidity data. Then, we study the empirical relationship between this indicator and a set of socioeconomic, health system and institutional controls at the Italian regional level over the period of 2011–2019. We find that institutional quality is a driver of population health. Furthermore, well-functioning local institutions and regions compliant with national standards in terms of public healthcare services (Essential Levels of Care) make socioeconomic context no longer relevant for population health, potentially reducing inequalities.
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Footnotes
1
For sake of simplicity, throughout the paper we use the terms “region” or “regional” to address all the territorial units, including the two provinces.
 
2
North points out that “the difference between formal and informal rules is one of degree…. formal rules can complement and increase the effectiveness of informal constraints. They may lower information, monitoring and enforcement costs and hence make informal constraints possible solutions to more complex exchange” [74] pp.46–47).
 
3
Studies on informal institutions often adopt different interpretations or refer to a few typologies. For an overview on the main types of informal institutions see Lauth [65].
 
4
Through the whole text, we have used the term ‘health’ to refer to the state of complete well-being, the term ‘healthcare’ (replaceable with health care) to refer to the improvement of health via the prevention, diagnosis, treatment, cure of disease, illness, injury, and the term ‘healthcare system’ to refer to an organization of people, institutions and resources that delivers healthcare services and that arranges for their financing to meet the health needs of target populations (for example, the National Health Service).
 
5
More extensively, the authors identify four mechanisms of connecting welfare state and health distribution: redistribution, compression, mediation and imbrication. For a detailed analysis, see Beckfield et al. [14].
 
6
Decommodification refers to “the extent to which individuals and families can maintain a normal and socially acceptable standard of living regardless of market performance” [39], p. 86).
 
7
An earlier version of the indicator can be found in Antonelli and Marini [6].
 
8
Self-reported health is a health measure based on survey questions. Although the literature has pointed out that it might be affected by self-reporting bias (see, for example, [9]), it remains one of the most popular ways to measure health.
 
9
For a detailed description of these variables, please check the online help of the operating system Health for All-Italia managed by the Italian Institute of Statistics (ISTAT) and its data warehouse (http://​dati.​istat.​it/​).
 
10
The 16 causes of death are: AIDS; circulatory system diseases; digestive system diseases; diseases of the endocrine glands, nutrition and metabolism; diseases of the genitourinary system; complications in pregnancy, childbirth and the puerperium (age 15-49); infectious diseases; diseases of the muscular system and connective tissue; diseases of the nervous system and sense organs; diseases of the skin and subcutaneous tissue; psychic disorders; respiratory system diseases; diseases of the blood and haematopoietic organs and immune disorders; trauma and poisoning; cancer; and other causes.
 
13
On this point see also Di Bella et al. [36].
 
14
The geometric mean is recognized as a more reliable measure to summarize indicators than the arithmetic mean being more robust against outliers [36]. Each domain has equal weighting for the final indicator as in the methodology used by Afonso et al. [2].
 
15
The ‘Well-Being and Sustainability’ (Benessere Equo e Sostenibile, BES) project aims at evaluating the progress of society considering a wide set of indicators. For details see: https://​www.​istat.​it/​en/​well-being-and-sustainability
 
17
See, for example, Beckfield et al. [13, 14] and the other references cited in the Introduction.
 
18
Pickett and Wilkinson [78] use income inequality as a macro-economic measure of the scale of differentiation of social status to test the effects of a more unequal society on a multidimensional well-being indicator.
 
19
Our choice is fundamentally linked to the Italian context, where the elderly holds a larger share of wealth than the young population, which gives the elderly a more stable socioeconomic condition [11].
 
20
Drinking habits could represent a proxy for sociality as, according to ISTAT [52], such habits are defined as a daily overconsumption of drinks or the so called “binge drinking” often associated to aggregate social behaviour, especially among young people, as highlighted by sociological literature [89, 92].
 
21
The Italian NHS was founded in 1978 and was based on the principle of universal coverage. It was financed mainly through general taxation and resources were allocated to the regions according to a capitation system.
 
23
Further details on the items of the IQI and the procedure of calculation is available on.
 
24
Regarding the health sector, De Luca et al. [33] provide a regional analysis investigating the effect of the institutional quality, as measured by the IQI, on Caesarean section rates (used as a measure of healthcare inappropriateness) and on health outcomes, as measured by reductions in heart attack, hip fracture and stroke mortality rates.
 
25
See Sect. Institutions and health: an overview for literature references.
 
26
The original ISTAT data concern “dirty streets”. We then take the complementary percentage and obtain the IV ‘Clean streets’ used in our analysis.
 
27
When we replace IQI with its two components, in the first-stage we have to instrument two variables (‘Government effectiveness’ and ‘Rule of law’) and therefore we need two instruments.
 
28
For a more specific analysis on this argument see Cirulli and Marini [27].
 
29
Stock-Yogo weak ID test critical values for F(1, 20) are 16.38 (10% maximal IV size), 8.96 (15% maximal IV size), 6.66 (20% maximal IV size) and 5.53 (25% maximal IV size), while those for F(2, 20) are 7.03 (10% maximal IV size), 4.58 (15% maximal IV size), 3.95 (20% maximal IV size) and 3.63 (25% maximal IV size).
 
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Metadata
Title
Do institutions matter for citizens’ health status? Empirical evidence from Italy
Authors
M. Alessandra Antonelli
Giorgia Marini
Publication date
09-05-2024
Publisher
Springer Berlin Heidelberg
Published in
The European Journal of Health Economics
Print ISSN: 1618-7598
Electronic ISSN: 1618-7601
DOI
https://doi.org/10.1007/s10198-024-01689-9