“…The Italian health system is considered one of the most decentralized in Europe, along with the systems of Austria and Spain (European Committee of the Regions, 2017), and it is quite similar, in health policy, to a federal state (OECD, 2019). Thus, all the sub-national units (19 regions and 2 autonomous provinces) enjoy significant autonomy in designing the organization and the delivery of their healthcare systems (Palermo & Valdesalici, 2019;Terlizzi, 2019). This organizational and policy autonomy has led to a significant variety in the design of regional healthcare systems (Nuti et al, 2016) that is completely beyond the control of the state.…”