Centralised versus decentralised funding of evaluative research: Impact on medical technology policy in Italy

Medical technology assessment in Italy is considered to have had scant impact on policy. Government has played a limited role in financing evaluative research and increased public funding might therefore be expected to have a positive effect on the contribution that this activity makes to policy. The choice of arrangements for such funding, however, must take account of the broader institutional context in which these operate. Intergovernmental relations in any country are inherintly difficult due to the fact that the distribution of powers is in general poorly specified and to a tendency for central government to try to impose itself. Budgetary difficulties may exacerbate the problem. Italy has quite a decentralised system of government and there has been significant disagreement over how to interpret the intergovernmental distribution of powers, including those relating to health care. Central government has also had difficulty in that sector making lower governments accountable for how they spend their central grants and for budget deficits. This has created serious problems for the implementation of medical technology policy developed at the centre. This state of affairs counsels against adopting funding arrangements for evaluative research in which central government plays a dominant role. Probably the most appropriate solution is that of a partnership between the centre and the Regions with each party having an equal say on the medical technologies studied, the evaluative methodologies adopted and how the data produced are used in policy development. This would mean central government espousing a new philosophy in its relationship with lower governments, based on non-hierarchical interaction through a process of collaboration, negotiation, bargaining and compromise. To the degree that this is possible, it could be expected that the impact of technology assessment on policy development but in particular on policy implementation would be improved. There is however a risk that the contribution of technology assessment in this regard may be constrained in a context such as Italy where the private health sector plays an important role in determining diffusion and utilisation patterns. This may also be true for national health services in the process of adopting managed competition models which decentralise medical technology decisionmaking.