**2. Theoretical frameworks**

As a consequence of NPM reforms, especially those concerning PMS, academics and international organizations such as the World Health Organization (WHO) and the Organization for Economic Cooperation and Development (OECD) developed conceptual frameworks and models in order to help countries in building effective tools (Arah et al., 2006; Kelley et al., 2006; Murray & Evans, 2003; Smith, 2002; Veillard et al., 2005).

Performance Measurement

**Regions** 

Friuli Venezia

Emilia

balanced across Italian Regions (see table 1).

**Regions participating on the study** 

Features of the Italian Regional Healthcare Systems: Differences and Similarities 301

A total of 15 Regions (over 21) participated in the study. Some Regions did not participate in the study because of institutional reasons such as the election or judgmental inquiries. Taking into account these issues the answer rate was high and the responses were quite

**Area Population** 

Lombardy Yes North 9,545,441 45 Bolzano Yes North 487,673 1 Trento Yes North 507,030 1 Veneto Yes North 4,773,554 23

Giulia Yes North 1,212,602 9

Liguria Yes North 1,607,878 8

Tuscany Yes Centre 3,638,211 16 Umbria Yes Centre 872,967 6 Marche Yes Centre 1,536,098 5

Basilicata Yes South 591,338 4

Sardinia Yes South 1,659,443 12

Romagna No North 4,223,264 17 Valle d'Aosta No North 124,812 1 Sources: Minister of Health, 2010 data and National Institute for Statistics. Table 1. A snapshot of the main statistics and comments of the IHRSs

PMSs which were collected in a research report (Nuti & Vainieri, 2009) .

analysis and the secondary data collected during the research.

Piedmont Yes North 4,352,828 21 Recovery Plan (2010)

Campania Yes South 5,790,187 19 Recovery Plan Apulia Yes South 4,069,869 10 Recovery Plan (2010)

Sicily Yes South 5,016,861 18 Recovery Plan

Lazio No Centre 5,493,308 21 Recovery Plan Abruzzo No South 1,309,797 4 Recovery Plan Molise No South 320,074 1 Recovery Plan Calabria No South 1,998,052 11 Recovery Plan (2009)

Conducted interviews generally lasted between 1 and 2 hours. They were recorded and sent to the interviewees for their validation. In addiction preliminary results of the cross-regional analysis were presented to those who participated in the study in a feedback seminar held in 2009. The discussions evolved on this occasion represented an effective means of the crossvalidation of the preliminary interpretations on the IHRSs responses on the characteristics of

Findings coming from interviews are also supported and integrated by the documental

**N° of Public Health Authorities** 

**Financial deficit** 

Recovery Plan (deficit covered by other regional resources)

Recovery Plan (deficit covered by other regional resources)

Both WHO and OECD based their frameworks on three main goals of health systems: (a) health improvement and outcomes; (b) responsiveness and access; and (c) assuring fairness of financial contribution. (Arah et al 2003).

These organizations declined these goals into four dimensions of performance: (a) health improvement/outcomes (b) responsiveness (c) equity, (d) efficiency.

Using these four dimensions, Hurst & Jee Hughes (2001) compared PMS adopted by a group of countries. The study highlights that countries do not covered all dimensions moreover often common dimensions are drill down differently.

On the basis of this evidence a first aim of this paper is to map the differences and similarities of IRHSs regarding the dimensions of performance monitored by Regional top managers and/or policy makers.

Another burning topic related to PMS in healthcare is the use of pay for performance mechanism as a governance tool (Van Herck et al 2010, Mannion & Davies 2008).

It is recognized that management tools should be managed in a coordinated way, especially the linkages between rewarding system (one of the two perspective of the pay for performance) and budgeting (Flamholtz et al., 1985; Ouchi, 1979). The connection between them is a crucial factor that can determine the effectiveness of PMS at the organizational level. To this extent it appears worthy to analyze the differences in the connection between PMSs and the rewarding system.

Finally another important topic related to PMS is benchmarking. Arah et al (2003) pointed out that a group of countries, that adopted a national PMS in health care, uses benchmarking as a mechanism to drive change in terms of improvement. In this perspective benchmarking is applied in order to gather information which can help the organization to improve its performance (Watson, 1993).

Although benchmarking gained growing relevance in health PMS at several levels, from international to organizational level (Johnston, 2004; NHS executive, 1999; Pink et al,2001; Nuti et al. 2009), in the Italian health sector it was not widespread yet at national or regional level (Banchieri, 2005).

In such circumstances a last issue that the empirical study aims to analyze regards differences and similarities in the attitude of Italian Regional Health System (IHRS) towards the use of benchmarking.
