LAUSR

Italy is a large European country of around 60 million inhabitants, and its territory is divided into 20 regions, all governed by elected politicians [1]. Since 1976, Italy has adopted a National Health Service (NHS), which provides universal coverage funded by general taxation and services free of charge at the point of delivery [2]. Starting from 1992, the Italian NHS has been increasingly decentralized, with many powers devolved to regions. This has gradually transformed the Italian NHS into several uneven regional health services (RHSs) [1]. Italy was the first European country dramatically hit by the COVID-19 pandemic in early 2020, especially in the North. In particular, the number of victims was dramatically high in Lombardy (capital Milan), whilst much lower in Veneto (capital Venice), the two neighboring regions first hit by the pandemic [1]. Veneto is a large region (18,345 square kilometers) of around 5 million inhabitants located in the north-east of Italy. It has been always governed in the last decades by centre-right political coalitions. The RHS is divided into nine local health authorities (AULSS), headed by general managers appointed at the regional level. AULSSs manage all the healthcare services delivered within their territory. The only exceptions are three autonomous hospital trusts (AO), of which two include the biggest hospitals in the region and the third one is specialized in oncology. The territory of each AULSS is subdivided in 26 districts, operational units that should organize the existing primary care services delivered in the community through public or private accredited facilities. The vast majority of central bodies have been merged in a single agency (Azienda Zero), which is responsible for AULSSs’ funding, planning, accounting, auditing and job posting. Starting from 2016, acute hospital facilities are systematically classified into a ‘hub and spoke’ conceptual network [3]. This has been the last step of a long and still ongoing process aimed at resetting the number of smaller acute hospitals that do not adequately meet safety and quality standards [4]. At present, there are 8 hubs (included the three AOs), 20 spokes (of which two private accredited hospitals), and 8 nodes (of which one private accredited hospital). All these hospitals have an Accident and Emergency service (AEs). Lombardy (23,863 square kilometers) lies in the centre of Northern Italy and is the most populated region of the country, with approximately 10 million inhabitants (3.5 million of them resident in the metropolitan area of Milan). Although traditionally characterized by a quite uneven political situation at the county level, Lombardy has been mainly governed by centre-right political coalitions in the last decades. Lombardy is the Italian region that has thrust more for a complete purchaser–provider split in its RHS, to foster market competition [2], particularly between public and private hospitals. A regional law issued in 2015 has drastically reformed the RHS local tier by separating the health services’ planning, purchasing and control from their provision on the regional territory. The first tasks have been devolved * Livio Garattini [email protected]