Health Policy 92 (2009) 313–321 Contents lists available at ScienceDirect Health Policy journal homepage: www.elsevier.com/locate/healthpol Funding health technologies in decentralized systems: A comparison between Italy and Spain Giulia Cappellaro a,b , Giovanni Fattore a,b,∗ , Aleksandra Torbica a,b a Centre for Research on Health and Social Care Management (CERGAS), Università Bocconi, Via Roentgen, 1, 20136 Milan, Italy b European Health Technology Institute for Socio-Economic Research, Brussels, Belgium article info Keywords: Medical devices Reimbursement Procurement Health basket Accessibility abstract Although cost-containment policies in Europe are focusing increasingly on medical devices, the impact of these policies has yet to be fully investigated, particularly in cross-country settings. This paper analyses coverage, procurement, and reimbursement of three inpa- tient medical devices (coronary stent, knee endoprosthesis and implantable cardioverter defibrillator) in the Italian and Spanish healthcare systems. The research was carried out by reviewing published and grey literature, as well as national and regional legislation; in addition, 19 experts from hospitals and the industry were interviewed. In both countries, there has been a shift in political power from the national to the regional level. At the same time, the content of public coverage has become more explicit. A major issue in both systems is reimbursement, i.e. the rules about funding the delivery of services included in the benefit baskets. The differences in procurement and funding mechanisms create different incentives that may have an impact on the uptake and diffusion of technolo- gies. These mechanisms, however, can only partially explain organizational and professional behaviour, as the use of technologies in both countries is mainly left to professionals who are exposed to a variety of incentives. There is limited direct and indirect guidance of national and regional authorities over the use of technologies in both countries. It is likely that the dif- ficult search for a balance between introducing innovations, containing costs and assuring equity will require stronger regulatory action in the next future. © 2009 Elsevier Ireland Ltd. All rights reserved. 1. Introduction There are considerable similarities between Italy and Spain in terms of historical development, economic struc- ture and institutional arrangements concerning healthcare. In both countries, the constitution grants a large degree of autonomy to regions or autonomous communities (ACs) with unique linguistic, cultural, geographic, or other char- acteristics. Decentralization has also been extended to all regions or ACs and increasingly encompasses the collection and distribution of tax revenues [1,2]. ∗ Corresponding author. Tel.: +39 02 58362581; fax: +39 02 58362598. E-mail address: giovanni.fattore@unibocconi.it (G. Fattore). Italy and Spain have important similarities from an economic perspective as well. Both are affluent countries whose main economic sectors (i.e. services, manufactur- ing, and agriculture) make similar relative contributions to country’s GDP, but with large regional variations. In Italy, economic disparities are associated primarily with the underdeveloped southern regions, which have weak economies and depend largely on the transfer of resources from the central government. In Spain, the different lev- els and rates of economic development are due to a variety of factors, with Basque Country, Catalonia, and Navarra having much stronger economies than other ACs in the country. While the ACs in Spain are based on historical and cultural characteristics, Italian regions are entities that were created after the Second World 0168-8510/$ – see front matter © 2009 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.healthpol.2009.05.004