Access to Healthcare in Rural Areas: a Hospital-level Analysis

Providing high-quality healthcare in rural and low-density areas is increasingly challenging due to aging, workforce shortages, and geographic isolation. This paper examines hospital performance in rural areas in Italy using hospital-level data from the National Clinical Outcomes Programme for the years 2015–2022. We analyze four key indicators capturing procedural efficiency, appropriateness of care, emergency responsiveness, and longer-term outcomes: timely surgery for femur fractures, primary caesarean section rates, 30-day mortality after acute myocardial infarction, and 1-year mortality after stroke.Combining these outcomes with detailed geographic, socio-economic and demographic information at the hospital catchment-area level, we assess whether hospitals serving predominantly rural populations perform differently from those serving more urban areas. The results show that rural localities are associated with significantly worse outcomes for three of the four indicators, even after controlling for healthcare supply, income, and regional fixed effects. These findings highlight persistent spatial inequalities in healthcare quality and the need for place-based policy interventions targeting rural areas.