Abstract
Recent demographic and economic developments are forcing National Health Services across Europe to provide care at a local level, as a strategy to contain costs without affecting service quality. A literature review concerning the management of healthcare services at a local level has revealed that research in this field is still in its infancy phase. Logistics/supply chain, performance management and economic evaluations were scarcely explored; this may have been due to the difficulty in finding reliable field data and in formalising complex and multi-disciplinary processes, typical of these research issues. In an attempt to fill literature gaps, the present study focused on the distribution management of health technologies at a local level. In particular, three research questions guided the study: i) What distribution models of health technologies have been developed by Local Health Authorities, and what are their features?; ii) What are the economic/quantitative performances of the distribution models previously identified?; and iii) What is the perception of the related qualitative performances? A multiple case study was designed for the analysis of different alternatives distributing health technologies (i.e. absorbent devices for incontinence, and devices for diabetes) at a local level, involving a sample of 12 Local Health Authorities within a specific Italian Region (Lombardy). After an analysis of distribution processes, using a benchmarking approach, specific Key Performance Indicators were constructed in order to compare the economic/quantitative performances achieved by each Authority. Quantitative data (target population, devices delivered and economic resources involved in the distribution processes), over the period 2011-2014, were collected in order to feed this set of Key Performance Indicators. Semi-structured interviews with LHAs' managers, collecting perceptions and qualitative data, were also conducted. Considering absorbent devices for incontinence, two main distribution models were identified: 1. Distribution through pharmacies: the patient goes to a pharmacy within the Local Health Authority territory and collects the authorised quantity of absorbent devices. 2. Home delivery: the Local Health Authority calls for a tender in order to identify and select provider(s) of products and logistics services. A distributor delivers the authorised quantity of products to the patient's domicile. Over the observed period, from an economic/quantitative point of view, home delivery provided a higher quantity of devices per patient; distribution through pharmacies presented a lower unit cost per patient; both the models, however, were equal in terms of unit cost of the service per device. The Local Health Authorities' managers perception of qualitative performances revealed that distribution through pharmacies is preferable for all the investigated dimensions (economic and logistic efficiency, responsiveness to users' need, and improving the Local Health Authorities' processes). The results of the study showed that, over the studied time frame, the performance of home delivery for absorbent devices changed (i.e. a larger quantity of devices distributed for a similar cost): one possible explanation for this could be founded on the regional tender for the supply and home distribution of devices adopted by some Local Health Authorities that started in 2012. Considering qualitative performances, distribution through pharmacies was the best option. In conclusion, based on the results of the study, while it is not possible to clearly identify the best distribution model for absorbent devices, from the interviews with the Local Health Authorities' managers it emerged that a new distribution model could be implemented, assuring quality and economic sustainability of the service, based on the voucher system: the patient would select the preferable location for the collection of products, and the type and the amount of absorbent devices, respecting a fixed economic sum as defined by the Local Health Authority (based on the clinical conditions of the patient). In Lombardy Region, distribution through pharmacies was the only distribution model identified for devices for diabetes, showing good performance over the studied period: a cost decrease was recorded, without a decrease in the quantity of delivered devices.