The impact of the Russia-Ukraine conflict on the energy expenditure of public Italian healthcare organizations – A nationwide interrupted series analysis
Keywords:
ITS model; sustainability; energy expenditure; hospital; Italian NHSAbstract
Background. Healthcare organizations are complex systems characterized as highly energy intensive structures. Italian healthcare organizations are under increasing pressure due to the external energy dependency, especially following the Russia-Ukrainian conflict. Indeed, the ongoing war has generated low energy availability and outbreaking energy costs, thus leading to the aim of the study that is to measure the effect of the Russia-Ukraine war on the energy expenditure of public Italian healthcare organizations.
Study design & methods. An Interrupted Times Series analysis was conducted across the period 2017-2022. Details were provided for the nineteen regions and two autonomous provinces. The outcome used was the energy expenditure amount across public healthcare organizations, a Poisson regression model was used. The revenues of public healthcare organizations were included as an offset variable to convert the outcome into a rate and adjust for any potential changes in revenues over time.
Results. The model suggested that there is strong evidence of a rise in the energy expenditure following the conflict, with an increase of 56% [relative risk (RR) 1.75] in Italy. All the Italian regions registered a notable increase of the energy expenditure in public healthcare organizations after the conflict, despite inter-regional variability was observed.
Conclusions. Several interventions have been carried out to support enterprises and healthcare organizations in managing energy expenditure increases, though National strategies and investments should be set up to guarantee public healthcare organizations’ sustainability in the long run.
References
1. Shen C, Zhao K, Ge J, Zhou Q. Analysis of Building Energy Consumption in a Hospital in the Hot Summer and Cold Winter Area. Energy Procedia. 2019 Feb;158:3735-40. doi: https://doi.org/10.1016/j.egypro.2019.01.883.
2. Yuan F, Yao R, Sadrizadeh S, Li B, Cao G, Zhang S, et al. Thermal comfort in hospital buildings – A literature review. J Building Engineering. 2022 Jan;45:103463. doi: https://doi.org/10.1016/j.jobe.2021.103463.
3. González González A, García-Sanz-Calcedo J, Salgado DR. A quantitative analysis of final energy consumption in hospitals in Spain. Sustain Cities Soc. 2018 Jan 1;36:169-75. doi: 10.1016/j.scs.2017.10.029.
4. Papadopoulos AM. Energy Efficiency in Hospitals: Historical Development, Trends and Perspectives. In: Energy Performance of Buildings. Cham: Springer International Publishing; 2016:217-33.
5. Rawtani D, Gupta G, Khatri N, Rao PK, Hussain CM. Environmental damages due to war in Ukraine: A perspective. Sci Total Environ. 2022 Dec;850:157932. doi: 10.1016/j.scitotenv.2022.157932. Epub 2022 Aug 9. PMID: 35952889.
6. Benton TG, Froggatt A, Wellesley L, Grafham O, King R, Morisetti N, et al. The Ukraine war and threats to food and energy security Cascading risks from rising prices and supply disruptions. London: Chatham House; 2022. ISBN: 9781784135225. doi: 10.55317/9781784135225. Available from: https://www.chathamhouse.org/2022/04/ukraine-war-and-threats-food-and-energy-security [Last accessed: 2025 Jan 10].
7. Eurostat. EU natural gas import dependency down to 83% in 2021 [Internet]. 2022. Available from: https://ec.europa.eu/eurostat/web/products-eurostat-news/-/ddn-20220419-1 [Last accessed: 2025 Jan 10].
8. Prohorovs A. Russia’s War in Ukraine: Consequences for European Countries’ Businesses and Economies. J Risk Financial Manag. 2022 Jul 2;15(7):295. doi: 10.3390/jrfm15070295.
9. Eurostat. Energy statistics database [Internet]. Available from: https://ec.europa.eu/eurostat/web/energy [Last accessed: 2025 Jan 10].
10. Heather P. The role of the traded gas hubs. In: A Series of Unfortunate Events - Explaining European Gas Prices in 2021. [Internet]. 2022. Available from: https://a9w7k6q9.stackpathcdn.com/wpcms/wp-content/uploads/2022/03/Insight-111-Explaining-European-gas-prices-in-2021-the-role-of-the-traded-gas-hubs.pdf [Last accessed: 2025 Jan 10].
11. Hudec M. Gazprom Did Not Reserve Gas Transit Capacity for June Via Slovakia, Poland [Internet]. Euractiv; 2022. Available from: https://www.euractiv.com/section/energy-environment/news/gazprom-did-not-reserve-gas-transit-capacity-for-june-via-slovakia-poland/ [Last accessed: 2025 Jan 10].
12. Osička J, Černoch F. European energy politics after Ukraine: The road ahead. Energy Res Soc Sci. 2022 Sep;91:102757. doi: 10.1016/j.erss.2022.102757.
13. Ferriani F, Gazzani A. The impact of the war in Ukraine on energy prices: consequences for firms’ financial performance [Internet]. 2022. Available from: https://ssrn.com/abstract=4216406 [Last accessed: 2025 Jan 10].
14. Eurostat. Final energy consumption by sector. 2024.
15. European Union. Country profiles [Internet]. Available from: https://european-union.europa.eu/principles-countries-history/country-profiles/italy_en [Last accessed: 2025 Jan 10].
16. Ministero della Salute, Italy. Servizio Sanitario Nazionale: i LEA [Internet]. 2022. Available from: https://www.salute.gov.it/portale/lea/dettaglioContenutiLea.jsp?id=5073&area=Lea&menu=vuoto [Last accessed: 2025 Jan 10].
17. Tediosi F, Gabriele S, Longo F. Governing decentralization in health care under tough budget constraint: What can we learn from the Italian experience? Health Policy (New York). 2009 May;90(2-3):303-12. doi: 10.1016/j.healthpol.2008.10.012. Epub 2008 Dec 5. PMID: 19058869.
18. de Rosis S, Guidotti E, Zuccarino S, Venturi G, Ferré F. Waiting time information in the Italian NHS: A citizen perspective. Health Policy (New York). 2020 Aug;124(8):796-804. doi: 10.1016/j.healthpol.2020.05.012. Epub 2020 May 28. PMID: 32624247.
19. Ferre F, de Belvis AG iulio, Valerio L, Longhi S, Lazzari A, Fattore G, et al. Italy: health system review. Health Syst Transit. 2014;16(4):1-168. PMID: 25471543.
20. Boccaccio A, Cinquini L, Nuti S, Vainieri M. La potenzialità della contabilità economico-patrimoniale per il confronto di performance tra Aziende Sanitarie: l’esperienza della Regione Toscana. In: Barretta A, Vagnoni E, eds. Il benchmarking in ambito sanitario. CEDAM; 2005.
21. Regione Piemonte. L’armonizzazione dei sistemi contabili e degli schemi di bilancio [Internet]. Available from: https://www.regione.piemonte.it/web/amministrazione/finanza-programmazione-statistica/bilancio/larmonizzazione-dei-sistemi-contabili-degli-schemi-bilancio [Last accessed: 2025 Jan 10].
22. Banca dati Amministrazioni Pubbliche (Open BDAP) [Internet]. 2024. Available from: https://openbdap.rg.mef.gov.it/ [Last accessed: 2025 Jan 10].
23. Lopez Bernal J, Cummins S, Gasparrini A. Interrupted time series regression for the evaluation of public health interventions: a tutorial. Int J Epidemiol. 2017 Feb 1;46(1):348-355. doi: 10.1093/ije/dyw098. PMID: 27283160; PMCID: PMC5407170.
24. Mariani NM, Pisani Ceretti A, Fedele V, Barabino M, Nicastro V, Giovenzana M, et al. Surgical Strategy During the COVID-19 Pandemic in a University Metropolitan Hospital in Milan, Italy. World J Surg. 2020 Aug 16;44(8):2471-6. doi: 10.1007/s00268-020-05595-y. PMID: 32418029; PMCID: PMC7229874.
25. Zagra L, Faraldi M, Pregliasco F, Vinci A, Lombardi G, Ottaiano I, et al. Changes of clinical activities in an orthopaedic institute in North Italy during the spread of COVID-19 pandemic: a seven-week observational analysis. Int Orthop. 2020 Aug 24;44(8):1591-8. doi: 10.1007/s00264-020-04590-1. Epub 2020 May 24. PMID: 32449043; PMCID: PMC7245996.
26. Cantù Elena, Anessi Pessina Eugenio, Persiani Nicolò. Armonizzazione contabile e revisione dei bilanci nelle aziende sanitarie pubbliche. L’aziendalizzazione della sanità in Italia. In: Cantù E, Ed. L’Aziendalizzazione della Sanità in Italia. Rapporto OASI; 2011:469-94.
27. Lopez Bernal J, Soumerai S, Gasparrini A. A methodological framework for model selection in interrupted time series studies. J Clin Epidemiol. 2018 Nov;103:82-91. doi: 10.1016/j.jclinepi.2018.05.026. Epub 2018 Jun 6. PMID: 29885427.
28. The R Project for Statistical Computing [Internet]. 2024. Available from: https://www.r-project.org/ [Last accessed: 2025 Jan 10].
29. Ricciardi W, Tarricone R. The evolution of the Italian National Health Service. Lancet. 2021 Dec;398(10317):2193-206. doi: 10.1016/S0140-6736(21)01733-5. Epub 2021 Oct 22. PMID: 34695372.
30. CERGAS-Bocconi University, Eds. Osservatorio sulle Aziende e sul Sistema sanitario Italiano. Rapporto OASI 2023 [Internet]. Milano: Egea; 2023. ISBN 978-88-238-4763-7. Available from: https://cergas.unibocconi.eu/sites/default/files/media/attach/Rapporto_OASI_2023_0.pdf?VersionId=o1QXm9qPi7HP3iz6bXzNpKBUK_CV_hpi [Last accessed: 2025 Jan 10].
31. European Central Bank. Inflation expectations and the strategy review [Internet]. Available from: https://www.ecb.europa.eu/home/search/review/html/inflation-expectations.en.html [Last accessed: 2025 Jan 10].
32. Pirrotta L, Guidotti E, Tramontani C, Bignardelli E, Venturi G, De Rosis S. COVID-19 vaccinations: An overview of the Italian national health system’s online communication from a citizen perspective. Health Policy (New York). 2022 Oct;126(10):970-9. doi: 10.1016/j.healthpol.2022.08.001. Epub 2022 Aug 4. PMID: 35987784; PMCID: PMC9349029.
33. Latha H, Patil S, Kini PG. Influence of architectural space layout and building perimeter on the energy performance of buildings: A systematic literature review. Int J Energy Environ Eng. 2022 Sep 8;14:431-74. doi: 10.1007/s40095-022-00522-4.
34. Autorità di Regolazione per Energia Reti e Ambiente (ARERA). Arera per il consumatore [Internet]. 2024. Available from: https://www.arera.it/it/index.htm# [Last accessed: 2025 Jan 1].
35. il Sole 24h Sanità. Fiaso e Aiop: un contributo straordinario agli ospedali per fronteggiare i rincari dell’energia [Internet]. 2022 Aug 30. Available from: sanita24.ilsole24ore.com/art/imprese-e-mercato/2022-08-30/cittadini-aiop-il-caroenergia-mette-rischio-diritto-salute-cittadini-121828.php?uuid=AEqbAWwB [Last accessed: 2025 Jan 10].
36. Depalo D. The side effects on health of a recovery plan in Italy: A nonparametric bounding approach. Reg Sci Urban Econ. 2019 Sep 1;78:103466. doi: 10.1016/j.regsciurbeco.2019.103466.
37. Tsagkaris C, Laubsher L, Matiashova L, Lin L, Isayeva A. The impact of energy shortages on health and healthcare in Europe. Health Sci Rep. 2023 Jan 26;6(2): e1075. doi: 10.1002/hsr2.1075. PMID: 36721397; PMCID: PMC9880148.
38. Zhang F, Wagner AK, Ross-Degnan D. Simulation-based power calculation for designing interrupted time series analyses of health policy interventions. J Clin Epidemiol. 2011 Nov;64(11):1252-61. doi: 10.1016/j.jclinepi.2011.02.007. PMID: 21640554.
39. Lopez Bernal JA, Lu CY, Gasparrini A, Cummins S, Wharham JF, Soumerai SB. Association between the 2012 Health and Social Care Act and specialist visits and hospitalisations in England: A controlled interrupted time series analysis. PLoS Med. 2017 Nov 14;14(11):e1002427. doi: 10.1371/journal.pmed.1002427. Erratum in: PLoS Med. 2018 Feb 26;15(2):e1002527. doi: 10.1371/journal.pmed.1002527. PMID: 29135978; PMCID: PMC5685471.
Downloads
Published
Issue
Section
License
Copyright (c) 2025 Elisa Guidotti, Marco Di Marco (Author)

This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Transfer of Copyright and Permission to Reproduce Parts of Published Papers.
Authors retain the copyright for their published work. No formal permission will be required to reproduce parts (tables or illustrations) of published papers, provided the source is quoted appropriately and reproduction has no commercial intent. Reproductions with commercial intent will require written permission and payment of royalties.