Tackling wicked problems in performance management and governance of public health: an empirical analysis of COVID-19 vaccination strategies

• DOI: https://doi.org/10.1108/IJPSM-07-2022-0163
• Published date: 31 January 2023
• Date: 31 January 2023
• Pages: 130-151
• Subject Matter: Public policy & environmental management,Politics,Public adminstration & management
• Author: Guido Noto,Anna Prenestini,Federico Cosenz,Gustavo Barresi

Tackling wicked problems in

performance management and

governance of public health:

an empirical analysis of COVID-19

vaccination strategies

Guido Noto

Department of Economics, University of Messina, Messina, Italy

Anna Prenestini

Department of Economics, Management and Quantitative Methods,

University of Milan, Milan, Italy

Federico Cosenz

Department of Political Sciences and International Relations, University of Palermo,

Palermo, Italy, and

Gustavo Barresi

Department of Economics, University of Messina, Messina, Italy

Abstract

Purpose –Public health strategies and activities are intrinsically complex. According to the literature, this

“wickedness”depends on the different interests and expectations of the stakeholders and the community, the

fragmented governance of the related services and the challenges in measuring and assessing public health

outcomes. Existent performance measures and management systems for public health are not designed to cope

with wickedness since they are mainly focused on inputs and outputs, neglecting broader outcomes because of

their long-term impact and the poor accountability of results. This research aims to tackle this shortfall by

adopting a dynamic performance management (DPM) approach.

Design/methodology/approach –This research explores the case of the vaccination campaign of a

Regional Health System. Through the analysis of an illustrative case study, the research discusses both

opportunities and limits of the proposed approach.

Findings –This research highlights that DPM supports performance management (PM) in wicked contexts,

thanks to the adoption of a system-wide perspectiveand the possibility of using simulation to experiment with

alternative strategies and benchmarking performance results with simulated trends.

Originality/value–This article tacklesa gap related tothe management ofwicked problems bothfrom a theory

and a practicalperspective. In particular, this researchsuggests the adoptionof DPM as an approach that may

supportpolicymakers in tacklingsocial pluralism, institutional complexityand scientific uncertainty all at once.

Keywords Public governance, Dynamic performance management, Simulation, Health systems, Case study,

COVID-19

Paper type Research paper

IJPSM

36,2

130

© Guido Noto, Anna Prenestini, Federico Cosenz and Gustavo Barresi. Published by Emerald

Publishing Limited. This article is published under the Creative Commons Attribution (CC BY 4.0)

licence. Anyone may reproduce, distribute, translate and create derivative works of this article (for both

commercial and non-commercial purposes), subject to full attribution to the original publication and

authors. The full terms of this licence may be seen at http://creativecommons.org/licences/by/4.0/

legalcode

The authors gratefully acknowledge Massimo Annicchiarico, general director of the Lazio regional

health department, and the key informants who participated in the research activities. The author would

also like to thank the editors and the anonymous reviewers.

The current issue and full text archive of this journal is available on Emerald Insight at:

https://www.emerald.com/insight/0951-3558.htm

Received 15 July 2022

Revised 3 November 2022

21 December 2022

Accepted 12 January 2023

International Journal of Public

Sector Management

Vol. 36 No. 2, 2023

pp. 130-151

Emerald Publishing Limited

0951-3558

DOI 10.1108/IJPSM-07-2022-0163

Introduction

Our society and its current challenges are growing in complexity, so modern literature defines

these last ones as “wicked”(Rittel and Webber, 1973;Head and Alford, 2015). Wicked does not

mean “evil”but refers to the impossibility of sharing an understanding of societal problems

and their definition. According to Head (2008) and Head and Alford (2015),“wickedness”

mainly depends on three key factors: social pluralism –i.e. the presence of multiple interests

and values of stakeholders; institutional complexity –i.e. the horizontal fragmentation and

multilevel governance characterizing public administrations; and scientific uncertainty –

i.e. the existence of gaps in reliable knowledge.

The emergence and persistence of wicked problems pose important challenges to

performance management (PM) in the public sector. PM is a methodological approach whose

main purpose is to guide organizations toward their objectives according to effectiveness,

efficiency and viability principles (Ouchi, 1979;Ferreira and Otley, 2009).

However, traditional PM systems are considered unable to cope with wicked problems

and their characteristics due to a static approach that does not account for feedback-loops and

non-linearities; and the inter-organizational fragmentation characterizing the public sector

that leads to poor accountability of results (Drury, 2014;Noto and Bianchi, 2015;Bianchi,

2016). To manage performance in wicked contexts, key solutions proposed by the literature

refer to the implementation of collaborative arrangements and co-production (Cristofoli et al.,

2017;Loeffler and Bovaird, 2019;Bianchi, 2021). These solutions have been designed and

tested to address the source of complexity deriving from institutional fragmentation

and social pluralism. However, to the best of the authors’knowledge, only some scholars

proposed solutions that also tackle scientific uncertainty.

Based on this gap, this work aims to illustrate how dynamic performance management

(DPM) can be used to cope with wicked problems in managing performance by tackling the

key limits characterizing traditional PM schemes.

DPM is a scientific approach combining system dynamics (SD) with PM theory (Bianchi,

2016). SD is a modeling technique that allows analysts to frame and simulate complex

systems and experiment with the models to design strategies for management and change

(Forrester, 1958).

The adoption of SD to tackle wicked problems finds its foundation in the methodological

opportunity to explore with simulation and engage with stakeholders (Vennix, 1999;

Sterman, 2000), thus providing more robust decision support to inter-institutional settings.

As such, SD allows analysts to adopt a holistic perspective to frame social pluralism,

institutional complexity and scientific uncertainty as the key factors characterizing wicked

contexts. As a result, it supports collaborative PM systems fostering a shared understanding

of their operating principles and processes.

This article focuses on public health and health prevention to explore and analyze the

contribution of SD in the case of wicked issues. Public health is considered fundamental in

tackling current social challenges such as the COVID-19 pandemic. In particular, the process

of planning and implementing vaccination campaigns in western Countries represents one of

the most challenging wicked problems in the current era.

The research begins with a literature review on wicked problems and PM in the public

sector. A second theoretical background explores the literature on PM in public health.

Building on this literature review, the article proposes and illustrates the DPM approach

(Bianchi, 2016,2021) as a systemic method for PM and governance in wicked contexts. Then,

the approach is tested on a case study exploring the vaccination campaign in Lazio –an

Italian regional health system that reported a successful experience with vaccination

operations –to explore how this health system could benefit from the adoption of DPM. The

case is developed by collecting empirical data, active engagement and discussing results in

focus groups with the Lazio regional managers. In the last section of the article, the case study

Managing

performance in

wicked

contexts

131